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uWORLD Cardio Pathophysiology
Terms in this set (280)
uWORLD: A 67 yo man comes to the ED due to progressive SOB and chest tightness. he has no lightheadedness or syncope. The patient takes lisinopril for HTN and metformin for Type 2 DM. He has smoked a pack of cigarettes daily of the last 40 years. The blood pressure cuff is inflated to 140 mmHg and the pressure is released very slowly. At 120 mmHg, intermittent Korotkoff sounds are head only during expiration. At 100mmHg, Korotkoff sounds are heard throughout the respiratory cycle
The physical examination finding can be seen in the following?
> Pulsus paradoxus is defined by a decrease in systolic blood pressure of > 10 mmHg with
. It is most commonly seen in patients with cardiac tamponade but can also occur in severe asthma, chronic obstructive pulmonary disease, and constrictive pericarditis
> Inspiration causes an increase in systemic venous return, resulting in increased right heart volumes. Under normal conditions, this results in expansion of the right ventricle into the pericardial space with little impact on the left side of the heart. However, in conditions that impair expansion into the pericardial space )eg, acute cardiac tamponade), the increased right ventricular volume occurring with inspiration leads to
bowing of the inter ventricular septum
toward the left ventricle. This leads to a decrease in left ventricular (LV) end-diastolic volume and stroke volume, with a resultant decrease in systolic pressure during inspiration.
A patient has pulses paradoxus. The patient is tachypeneic and unable to speak in full sentences. Examination revels prolonged expiration and prominent bilateral wheezing. Heart sounds are nonroman. Chest imaging shows a normal-sized heart and hyper inflated lungs with a flattened diaphragm. Beside ECG revels no intrapericardial fluid accumulation or pericardial thickening. Which of the following physiologic changes is most likely to provide immediate relief in this patient?
cAMP accumulation in smooth muscle cells
> Asthma and chronic obstructive pulmonary disease (COPD) exacerbation are the most frequent causes of pulses paradoxus in the absence of significant pericardial disease. Beta-adrengeric agonists control acute asthma and COPD exacerbations by causing bronchial smooth muscle relaxation via increase intracellular cAMP.
uWORLD: A 35 yo man is evaluated for progressive fatigue and SOB. Recently, he has noticed bilateral leg swelling and abdominal distention despite overall weight loss. He does not use tobacco, alcohol, or illicit drugs. Despite treatment, the patient dies several weeks later. Autospy revels significant endocardial thickening with dense fibrous deposits around the tricuspid and pulmonary valves as well as moderate pulmonary valve stenos. The left-sided cardiac chambers and valves are normal. Measuring the levels of which substances would have helped in diagnosing this patient?
Urinary 5-hydroxyindolearcretic acid
> Carcinoid syndrome typically presents with episodic flushing, secretary diarrhea and wheezing. It can lead to pathognomonic plaque-like deposits of fibrous tissue on the right-sided endocardium, causing tricuspid regurgitation and right-sided heart filature. Elevated 24 hour urnary 5-hydroxyindoleacetic acid can confirm the diagnosis.
> The autospy findings - endocardial thickening and fibrosis of tricuspid and pulmonary valves - are chracerstic of
carcinoid heart disease.
. Carcinoids are well-differentiated neuroendocrine turbos found most commonly in the distill small intestine and proximal colon, with a strong propensity for metastasis to the liver. These tumors secrete seers products (including histamine, serotonin, and vasoactive intestinal peptide) that are metabolized in the liver. In patients with liver metastasis, these hormones are relased directly into the systemic circulation, leading to carcinoid syndrome.
> Carcinoid heart diseases is caused by excessive secretion of
, which stimulates fibroblast growth and fibrognesis. Pathognomic plaque-like
deposits of fibrous tissue
occur most commonly on the
, leading to
, pulmonic valvulpathy, and right-sided heart failure )eg ascites, peripheral edema). Endocardial fibrosis and thickening are generally limited to the right heart as vasoactive products and inactivated distally by pulmonary vascular endothelial monoamine oxidase.
- Measuring of plasma cortisol: Used for diagnosing adrenal insufficiency and Crushing syndrome
- Measuring of homocysteine: elevation may contribute to arterial and venous thrombosis and to the development of atherosclerosis.
- Measuring of plasma phenylalanine: May be elevated in patients with phenylalanine hydroxylase deficiency, resulting in central nervous system damage/intellectual disability :
- Measuring of porphobilinogen: May be elevated in the porphyria, which are caused by deficiencies of the heme synthesis enzymes. The porphyries may produce cutaneous lesions, skin photosensitivity, or attacks of abdominal pain and neurological disturbances (acute intermittent porphyria)
- Measuring of vanillymandelic acid: by product of norepinephrine and epinephrine, and can be used to detect
and other tumors of neural crest origin
uWorld: A 62 yo woman comes to the hospital with intermittent but progressive substernal chest pain over the last 36 hours. Medical history includes HTN and hyperlipidemia, but the patient has been poorly compliant with her medication regimen and outpatient follow-up. She previously smoked a pack daily for 30 years but quit last year. Her blood pressure is 130/75 mmHg and pulse is 73/min. ECG on admission shows normal sinus rhythm with a 2-mm ST segment elevation in leads V2-V5. The patient is treated with medical management. However, on the fifth day of hospitalization she dies suddenly, despite adequate resuscitation. Which is the most likely cause of death in the patient?
> Rupture of the left ventricular free wall is a catastrophic mechanical complication of anterior wall myocardial infarction (MI) that usually occurs within the first 5-14 days after MI. Rupture leads to hemoperricardium and cardiac tamponade, causing profound hypertension and shock with rapid progression to pulseless electrical activity and death.
> This patient most likely died from profound hypotension due to
ruptured left ventricular free wall
. Her initial presentation of substernal chest discomfort and ST segment elevation in anterior precordial leads in consistent with acute
anterior wall myocardial infarction (MI)
. Free wall rupture is a catastrophic mechanical complication that usually occurs within the first 5-14 days after a large anterior transmural MI (from left anterior descending occlusion). During this timeframe, the infarcted myocardium is substantially weakened by coagulative necrosis, neutrophilic and macrophage infiltration, and enzymatic lysis of myocardial connective tissue. Abrupt rupture of the left ventricle leads to
. Patients have sudden onset of chest pain and
profound hypotension and shock
, with rapid progression to pulseless electrical activity and death.
> Carotid artery occlusion = can lead to ischemic symptoms (hemiparesis, vision changes) but does not typically cause sudden death.
> Hypertensive emergency can lead to aortic dissection = that typically presents with tearing chest or back pain. Hypertension and shock can occur with retrograde extension of the dissection into he pericardial cavity or contrary arteries, with resultant hemoperricardium or MI, respectively. However, this patient's presentation of intimal normal blood pressure and ST segment elevation is more suggestive of acute MI with subsequent cardiac rupture.
uWORLD: A 18 yo women is referred to cardiologist after a heart murmur is discovered during routine checkup. The patient is healthy and has no symptoms. Past medical history is unremarkable. She runs daily and wants to start actively training for a half marathon. She is concerned that the murmur is a sign of heart disease and would prevent her from pursuing her athletic activities. She has no family history of sudden cardiac death. Auscultation reveals a midsystolic click that is followed by a short late-systolic mummer at the cardiac apex. The mummer disappears with equating. This patient's condition is most likely related to an abnormality involving which of the following tissues?
> Cardiac auscultation in patients with mitral valve prolapse (MVP) typically reveals a non ejection (eg. mid systolic) click and mid- to late systolic mummer of mitral regurgitation. MVP is most often caused by defects in mitral valve connective tissue proteins that predispose to myxomatous degeneration of the mitral leaflets and chord tendineae.
> The presence of a midstylic click following to a mid- to late systolic mummer at cardiac apex that disappears with squatting is most consistent with
mitral valve prolapse
(MVP) with mitral regurgitation (MR). The click results from sudden tensing of the charade tendineae as they are pulled taut by the ballooning valve leaflets. The mummer is due to malalignment of the valve margins during systole.
that change left ventricular (LV) volume and cavity size can change the timing and intensity of the murmur.
from a standing position
increases venous return
, helping to bring the valve leaflets into a more normal anatomic arrangement. This, in turn, decrease the degree of MVP, causing a delay in the onset of click during systole, and systolic mummer typically becomes shorter or disappears.
> Hypertrophic cardiomyopathy (HCM) also presents with a systolic mummer at the cardiac apex that decreases in intestnity with squatting (due to increased left ventricle volume and decreased outflow tract obstruction). However, a mid systolic click, which is classic for MVP, is not heard with HCM.
uWORLD: A 66 yo man with DM is brought to the host pail due to sudden-onset chest pain and nausea. BP is 70/60 mmHg and pulse is 60/min. Lungs are clear on auscultation. ECG shows ST-segment elevation in leads II, III, and aVG. Chest x-ray is unremarkable. The patient is diagnosed with an inferior wall myocardial infarction. Emergency cardiac cauterization revel complete occlusion of the proximal right coronary artery. He is persistently hypotensive in the cardiac cauterization laboratory.
Which of the following hemodynamic findings is most likely to be obsessed (cardiac output, Pulmonary capillary wedge pressure, Central venous pressure; Will it increase/decrease?)?
Decrease Pulmonary Capillary Wedge pressure
Increase Central Venous Pressure
This patient is in cariogenic shock after suffering a left ventricular (LV) inferior wall MI. The inferior wall of the LV is supplied by the posterior descending artery, which arises off the dominant right canary artery. Because the right coronary artery also gives off marginal branches that supply most of the right ventricle (RV), inferior wall MI is often associated with r*right ventricular infarction(.
> Infarction of the RV results in decreased RV stroke volume, which in turn leads to
LV filling and
in spite of preserved LV systolic function (Frank-Starling mechanism). TV dilation and elevated diastolic pressures also cause a shift of the interventrciular septum toward the LV cavity, further impairing LV filling and cardiac output, contributing to systemic hypotension and shock. Because left-sided filling pressures are reduced,
pulmonary capillary wedge pressure
as it estimates left atrial pressure. In addition, patients have
elevated central venous pressure
due to RV dysfunction and impaired forward flow.
uWORLD: A 45 yo woman who recently immigrated to the US is hospitalized with exertion dyspnea and fatigue. She has no significant past medical history and takes no medication. The patient's BP is 110/80 mmHg and heart rate is 90/min and regular. After cardiopulmonary examination, the physician suspects mitral stenos. Which of the following is the most useful measure for assessing the degree of stenosis?
A2-to-opening snap time interval
> On auscultation, the best indicator of mitral stenosis (MS) severity is the length of time between S2 (specifically the A2 component, caused by aortic valve closure) and the opening snap (OS). The OS occurs due to abrupt tensing of the valve leaflets as the mitral valve reaches its maximum diameter during forceful opening.
> Left-sided S3 and/or S4 gallops are generally absent in MS, since left ventricular filling is normal or decreased.
Ex. A 4 month old baby is brought to the cardiology clinic by his parents for continued followed-up of tetralogy of Fallot. The diagnosis was made during routine antenatal sonography, and the pregnancy and delivery were otherwise uncomplicated. The infant has been seen frequently in the clinic and has not had any cyanosis, respiratory distress, and difficulty feeding. The parents become concerned when their son's surgical plan is discussed because he does not have the clinical signs that other children with metrology of Fallot demonstrate. Which is the major determinant of symptoms severity in this condition?
Right ventricular Outflow Tract Obstruction
Tetraology of Fallot
is characterized by ventricular septal defect (VSD), overriding aorta, right ventricular outflow tract (RVOT) obstruction and right ventricular hypertrophy. The VSD generally is large, which allows for haul pressure in the right and left ventricles. Therefore, it is the amount of
that determines how much deoxygenated blood is delivered to the systemic circulation.
> Infants with no or minimal RVOT obstruction, such as this patient, deliver more deoxygenated blood to the lungs and appear cyanotic. The degree of RVOT obstruction is
and can increase suddenly, leading to profound cyanosis ("tet spells". These can be caused by dehydration or hyperventilation but are usually idiopathic.
uWORLD: A 62 yo man comes o the office for follow-up of hypertension. He was diagnosed with HTN 10 years ago and has been treated with a number of different medications. However, the patient has had to discontinue several medications due to side effects such as dizziness, palpitations, and headaches. Currently he takes ramipril and chlothalidone and is tolerating them well. BP is 160/92 mmHg and was 158/89 mmHg at his most recent prior visit. ECG shows sinus bradycardia (55/min) with PR interval prolongation (280 sec). Which of the following medications would be most effective for lowering this patient's blood pressure without worsening his ECG abnormalities?
> DO NOT GIVE Non-hydropyrmidine Ca2+ channel blockers (Verapamil, Diltilzaem) OR beta-blockers because they depress the AV node further worsening the bradycardia.
> Calcium channel blockers inhibit the L-type channel on vascular smooth muscle and cardiac cells. Dihydropyridines (eg nifedipine, amlodipine) primary affect peripheral arteries and cause vasodilation. Nondihydropyridines (eg. verapamil, diltiazem) affect the myocardium and can cause bradycardia and slowed atrioventricular conduction.
uWORLD: A 45 yo man comes to the ED because of severe chest pain, diaphoresis, and palpitations. The patient dies two hours after the onset of his symptoms. Autospy reveals 100% occlusion of the left anterior descending artery. At the time of the patient's death, light microscopy of the affected myocardium would most likely demonstrate which of the following?
> 0-4 hours - minimal change
> 4-12 hrs- early coagulation necrosis, edema, hemorrhage, wavy fibers,
> 12-24 hrs - coagulation necrosis and marginal contraction band necrosis
> 1 to 5 days - coagulation necrosis and neutrophilic infiltrate
> 5 to 10 days - macrophage phagocytosis of dead cells
> 10 to 14 days - granulation tissue and neovascularization
> 2 weeks to 2 months - collagen deposition/scar formation
uWORLD: A 60 yo man comes to the ED with acute substernal chest pain, nausea, and diaphoresis. The patient has a history of liver cirrhosis, hypertension, and hyperlipidemia. He quit smoking 3 months ago but previously smoked a pack of cigarettes daily for 25 years. ECG shows ST elevations in leads II, III, and aVF. He is diagnosed with a MI and, after careful discussion of risks and benefits, repercussion therapy is not performed due to underlying cirrhosis and history of vatical bleeding. The patient is eventually discarded from the hospital with conservative management. Twelve day after his MI, he dies suddenly. Light microscopy would most likely show what changes to the myocardium of the inferior wall?
Granulation tissue with neovascularization
> Sudden cardiac death
after MI is most likely due to
originating from the infarcted myocardium. The microscopic diagnosis of MI depends on the presence of necrotic myocardium, with areas of acute inflammation and necrosis separated from viable myocardium. After the initial event, several characteristic microscopic changes occur in the infarcted zone in a specifyic temporal sequence with some overlap in different stages.
During the second week
after MI, the damage tissue is replaced by
is found in the infarct zone.
uWORLD: A 72 yo man with long-standing dyspnea was seen int eh clinic after experiencing an episode of syncope. Physical examination showed weak and slowly rising arterial pulses. Cardiac auscultation showed a harsh mid systolic mummer best heard at the second right intercostal space with decreased intensity of the second heart sound. ECG and echocardiogram confirmed the diagnosis of severe aortic stenosis. Two months later, the patient comes to the ED with palpitations and increased SOB. His blood pressure is 90/60 mmHg and his heart rate is 130/min with an irregularly irregular rhythm. ECG shows new-onset arterial fibrillation without significant ST-segment or T-wave changes. Chest x-rays show bilateral pulmonary edema. Which of the following hemodynamic changes is most likely associated with this patient's current presentation?
Sudden decrease in left ventricular preload
> Patients with severe AS already have reduced cardiac output due to significant valvular obstruction, which can be exacerbated by the sudden
loss of normal atrial contraction
that contributes to ventricular filling. Atrial contraction is especially important for these patients as many have concentric left ventricular (LV) hypertrophy and therefore reduced LV compliance. As a result, they become dependent on atrial contraction to maintain adequate LV filling.
> In patients with chronic aortic stenosis, and concentric left ventricular hypertrophy, atrial contraction contributes significantly to left ventricular filling. Loss of atrial contraction due to atrial fibrillation can reduce left ventricular preload and cardiac output sufficiently to cause systematic hypertension. Decreased forward filling of the left ventricle can also result in backup of blood in the left atrium and pulmonary veins, leading to acute pulmonary edema.
uWORLD: An 82 yo man comes to the office due to progressive dyspnea and fatigue over the last ear, which now limits his daily activities. He also noticed bilateral swelling of his feet. The patient has HTN, which is controlled with amlodipine. His BP is 122/72 mmHg and pulse is 55/min. Physical examination reveals elevated jugular venous pressure with rapid 'y' descent and a prominent S4. Abdominal examination shows moderate ascites. The patient has 3+ bilateral lower extremity pitting edema. Echocardiogram reveals left atrial enlargement with marked left ventricular hypertrophy and normal left ventricular ejection fraction. Complete good count, basic metabolic panel, and serum, and urine protein electrophoresis are within normal limits. What is the most likely diagnosis of this patient?
> This patient's clinical presentations (eg. progressive exertion dyspnea, edema, ascites, elevated jugular venous pressure and rapid 'y' descent, prominent S4) and echocardiogram findings (eg. left atrial enlargement, left ventricular hypertrophy, normal ejection fraction) are consistent with
diastolic heart failure
due to restrictive cardiomyopathy.
can be idiopathic or caused by infiltrative disease (eg, amyloidosis, sarcoidosis, hemochromatosis), radiation fibrosis, or endomycardial fibrosis. Although most cases are associated with normal ventricular wall thickness. Infiltrative conditions such as cardiac amylosisis may lead to significant
. Infiltrative diseases can also cause conduction system abnormalities (eg, bradycardia) that may ultimately require pacemaker implantation*
The fourth heart sound (S4) is a low frequency sound heard at the end of diastole just before S1. It is due to decreased left ventricular compliance and is often associated with _____________________ and ____________________.
Restrictive cardiomyopathy; left ventricular hypertrophy
uWORLD: A 54 yo Caucasian male comes to the ED with retrosternal chest pain of 30 min duration. The patient also complains of sweating and mild dyspnea. A single table of nitro is delivered sublingually, and the patient's pain decreases significantly. The patient has experienced several similar episodes of pain over the last 12 hours, all of which resolved spontaneously. Which of the following ultrastructural changes would most likely indicate irreversible myocardial cell injury in this patient?
> Mitochondrial vacuolization is typically a sign of irreversible cell injury, signifying that the involved mitochondria are permanently unable to generate ATP.
> Myofibril relaxation
> Disaggregation of polysomes denotes the dissociation of rRNA from mRNA in reversible ischemic/hypoxic injury.
> Disaggregation of granular and fibrillar elements of the nucleus is associated with reversible cell injury
> Triglyceride droplet accumulation is characteristic of reversible cell injury, especially in hepatocytes, and also in striated muscle cells and renal cells.
> Glycogen loss is another early and reversible cellular response to injury
uWORLD: A 45 yo man comes to the clinic due to recurrent palpitations accompanied by chest discomfort and SOB. A year ago, he was diagnosed with paroxysmal atrial fibrillation treated with rate control using a beta blocker. Past medical history is also significant for HTN and obesity. ECG shows left atrial enlargement, normal left ventricular ejection fraction, and no significant valvular disease. 24-hour Holter monitoring reveals bursts of atrial fibrillation associated with the patient's symptoms. He is initiated on dofetilide to maintain normal sinus rhythm. This medication exerts its main effect on which portion of the action potential curve?
Phase 3 (last repolarization)
> Class III antiarrhymic drugs amiodarone, stall, dofetilide) predominately block potassium channels and inhibit the outward potassium current during the phase, leading to prolongation of repolarization, action potentials duration, and the QT interval on ECG.
uWORLD: A 42 yo male is brought to the ED complaining of severe headaches and oliguria. His blood pressure is 240/150 mmHg and his heart rate is 90/min. On ophthalmologic exam, there is papilledema bilaterally. Which of the following is the most likely pathological process associated with his patient's condition?
Onion-like concentric thickening of arteriolar walls
> This patient presents in hypertensive crisis, a condition defined as a persistent diastolic pressure exceeding 130 mmHg that is often associated with acute vascular damage. Hyper plastic arteriolosclerosis, which can result from diastolic pressures >120-130 mmHg, presents as onion-like
> Hyperplastic ateriolosclerosis in renal arterioles can result from and perpetuate malignant hypertension. The pathological lesion is an onion-like concentric thickening of arteriolar walls in the renal vasculature and elsewhere.
uWORLD: A 35 yo perviously healthy man is brought to the ED after being involved in a motor vehicle accident. He has significant blunt chest and head trauma. Shortly after he arrives, his blood pressure drops suddenly and he begins experiencing respiratory distress. On physical examination, the patient is tachycardia and tachypneic. His lungs are clear to auscultation with vesicular breath sounds heard bilaterally. He has jugular venous distention, and his systolic blood pressure falls 15 mmHg with inspiration. Which of the following is the most likely cause of this patient's deterioration?
> The combination of jugular venous distention, hypotension, and muffled heart sounds is highly suggestive of cardiac tamponade. Tachycardia and pulses paradoxus are also frequently seen with tamponade. Lung examination is normal, which can help distinguish cardiac tamponade from tension pneumothorax.
> During inspiration, the pressure in the pleural space and lung interstitial decreases, increasing pulmonary vascular capacitance. This causes a fall in venous inflow to the left heart, resulting in decreased left ventricular stroke volume and a drop in systolic blood pressure (normally < 10 mmHg). The inspiratory drop in systolic blood pressure is exacerbated in cardiac tamponade due to extrinsic compression of the ventricles.
________________ can cause hypotension, tachycardia, tachypnea, and jugular venous distention. It can result from blunt or penetrating chest trauma that injures the visceral pleura or tracheobronchial tree. However, tension pneumothorax would cause absent breath sounds and hyper resonance to percussion on the affected side
Ex. A 19 yo man comes to the office due to difficulty seeing and blurred vision, which have worsened slowly over the past year. He is a second year college student pursuing a degree in biochemistry. His grades are excellent, but he is concerned about the effect his poor vision has had on his classes this semester. The patient is also an avid swimmer. He weighs 71 kg (156.5 lb) and is 195 cm (6 ft 5 in) tall. Physical examination shows the breastbone dips inwards or protrudes outwards. This patient is most likely to die from which condition
> Marfan syndrome (MFS) is one of the most common inherited connective tissue disorders. This condition is caused by a genetic defect in the glycoprotein
and results in abnormalities in the skeleton (eg, long extremities, scoliosis, precuts excavated), eyes (eg, ectopic lentil), and cardiovascular system (eg, aortic root disease)
> The 2 most common cardiac abnormalities seen in MFS patients are
mitral valve prolapse
cystic medial degeneration of the aorta
. In more than 75% of MFS patients, cystic medial degeneration of the aorta results in aneurysmal dilation. If untreated, this can cause
, the most common cause of death in MFS patients.
> Cardiovascular lesions are the most life-threatening complications associated with Marfan syndrome. Early-onset cystic medial degeneration of the aorta predisposes to aortic dissection, the most common cause of dearth in these in these patients.
uWORLD: A 66 yo man is evaluated for recurrent syncope. He has had 3 episodes of dizziness and palpitations followed by brief loss of consciousness over the last 6 months. He has no chest pain or dyspnea. The patient has a history of hypertension and hyperlipidemia. There is no family history of sudden death. Initial evaluation shows normal ECG and echocardiogram. A cardiac electrophysiologic study is performed. During the study, intravenous infusion of a medication is administered and produces increase contractility and decrease vascular resistance. What is most likely the medication?
> Isoproterenol is Beta-1 and beta-2 adrenergic receptor agonist (nonselective beta adrenergic agonist) that causes increased myocardial contractility and decreased systemic vascular resistance.
> Norepinephrine acts on alpha-1 receptors, causing vasoconstriction and an increase in systemic vascular resistance. Norepinephrine also acts as a weak agonist at beta-1 receptors, with a modest increase in myocardial contractility.
uWORLD: A 24 yo man is evaluated after an episode of syncope. He was out jogging when he felt lightheaded and passed out, but he did not sustain any head injury. The patient has had 2 similar episodes of lightheadedness while jogging over the last year, but this was the first time he passed out. He considers himself in good health and has no other medical problems. The patient does not use tobacco, alcohol, or illicit drugs. His father died suddenly at age 30. On physical examination, he has a harsh systolic murmur. Transthoraic echocardiography shows asymmetric inter ventricular septal hypertrophy. The patient's symptoms are most likely explained by left ventricular outflow obstruction created by which of the following structures?
Mitral valve leaflet and inter ventricular septum
> This patient's presentation suggests
hypertrophic cardiomyopathy (HCM), an autosomal dominant disorder resulting from mutations in cardiac sarcomere proteins. HCM is characterized by asymmetric ventricular septal hypertrophy and variable, dynamic
left ventricular outflow tract (LVOT) obstruction
. Systolic anterior motion of the
interventricular septum* can cause eccentric mitral regurgitation and exacerbate LVOT obstruction.
> Examination often reveals a harsh crescendo-decrescendo systolic mummer at the apex and left lower sternal border, which changes in intensity with physiologic maneuvers.
> In patients with hypertrophic cardiomyopathy, dynamic left ventricular outflow tract obstruction is due to abnormal systolic anterior motion of the anterior leaflet of the mitral valve toward a hypertrophied inter ventricular septum.
uWORLD: A 54 yo man comes to the ED with severe fatigue and dyspnea. He has a long history of progressively worsening heart failure that has been resistant to treatment with medications. He was treated with chest radiation several years ago for Hogdkin's disease and has been in remission ever since. The patient is admitted to the hospital, but his condition continues to deteriorate despite aggressive therapy. He dies 3 days later and an autospy is performed. Gross inspection of his heart shows dense, thick fibrous tissue in the pericardial space between the visceral and parietal pericardium. Which of the following signs would most likely have been detected during physical examination of this patient?
> This patient has thick fibrous tissue in the pericardial space, a finding which is diagnostic for constructive pericarditis. This dense, rigid pericardial tissue encases the heart and restricts ventricular filling, causing low cardiac output and right-sided heart failure resistant to medication. Jugular venous pressure (JVP) is almost always increased in patients with constrictive pericarditis due to the restriction in right ventricular filling capacity. Although JVP normally drops during inspiration, patients with constrictive pericarditis frequently have a paradoxical rise in JVP, a finding known as
. This occurs because the volume-restricted right ventricle is unable to accommodate the inspiratory incase in venous return.
> Constrictive pericarditis is a chronic condition in which the normal pericardial space is replaced by a thick, fibrous shell that restricts ventricular volumes and eventually causes heart failure. Impaired right ventricular filling leads to increased jugular venous pressure and often results in a positive Kussmaul sign. There may also be a pericardial knock, which occurs earlier in diastole than the S3 heart sound.
uWORLD: A 10 yo immigrant from Eastern Europe is brought to the office due to exertion dyspnea and fatiguability. The boy tires easily when walking and cannot keep up with his peers at the playground. According to his parents, he was diagnosed with a congenital heart disease in infancy, for which they refused treatment. They cannot recall the details of his diagnosis. The patient also has had occasional respiratory infections throughout childhood that have not required hospitalization. He takes a daily multivitamin and no medications. He has received only a few childhood vaccinations based on parental preference. The patient has no family history of heart disease. Physical examination shows toe cyanosis and clubbing but no finger abnormalities. All extremity pulses are full and equal. Which of the following is the most likely diagnosis?
Patent ductus arteriosus
> Patent ductus arteriosus (PDA) is a vascular connection between the main pulmonary artery and the aorta that normally obliterates after birth. Clinical features vary depending on the size. Small PDAs are characterized by a
continuous, machinelike murmur
(left-to-right shunting) with no significant symptoms. Large PDAs can present anytime during childhood with progressive pulmonary hypertension and reversal of the shunt to right-to-left. The characteristic continuous mummer decreases as the pulmonary pressure rises and ultimately disappears.
> Typical consequences include heart failure (eg. shortness of breath, fatiguability), and cyanosis (
). The cyanosis and clubbing are most pronounced in the lower extremities (
differential cyanosis and clubbing
) because the PDA delivers unoxygenated blood distal to the left subclavian artery.
.> Differential clubbing and cyanosis without blood pressure or pulse discrepancy are pathognomonic for a large patent ductus arteriosus complicated by Eisenmenger syndrome (reversal of shunt flow from left-to-right to right-to-left). Severe coarctation of the aorta can cause lower extremity cyanosis. Right-to-left shunting in patients with large septal defects are tetralogy of Fallot results in whole-body cyanosis.
__________________ is most commonly located in the juxtaductal region just distal to the left subclavian artery. It typically presents in children and adults as a blood pressure discrepancy and
pulse delay between the upper and lower extremities
Coarctation of the aorta
_____________________ is generally characterized by whole-body cyanosis at birth as the result of right-to-left shunting across the ventricular spatial defect. The right-to-let shunt is intracardiac, and therefore cyanosis typically involves the whole body.
Tetralogy of Fallot
uWORLD: A 21 yo Caucasian male presents to the ED following an episode of syncope. The syncopal episode was not provoked by any activity or circumstance, nor was it proceeded by lightheadedness. The patient has no significant past medical history and he is not taking any medications. An ECG obtained in the ER reveals QT-interval prolongation but is otherwise unremarkable. Assuming this is an inherited condition, the relevant mutation most likely affects which structure?
Membrane potassium channel protein
> This patient's sudden-onset syncopal episode suggests a sudden cardiac arrhythmia. QT prolongation is an otherwise healthy young individual is usually congenital. The mutation most likely to cause QT-interval prolongation can be determined based on an understanding of cardiac electrophysiology. The QT-interval reflects the cardiac myocyte action potential duration, which is determined in part by K+ currents through channel proteins.
> Unprovoked syncope is a previously asymptomatic young person may result from a congenital QT prolongation syndrome. The two most important congenital syndromes with QT prolongation - Romano-Ward syndrome and Jervell and Lange-Nielson syndrome - are thought to result from mutations in a K+ channel protein that contributes to the delay rectifier current (IK) of the cardiac action potential.
Mutations in cardiac cell ________________ underlie hypertrophic cardiomyopathy (HCM). Although HCM may present as syncope in a previously asymptomatic young person, the syncope of HCM is typically provoked by exertion. Additionally, AT prolongation is not generally found in HCM.
Sarcomere proteins (eg. beta-myosin heavy chain)
A 64 yo man comes to the ED due to flank discomfort and red urine. He has a history of HTN and Type 2 DM. Three mounts ago, the patient had an ischemic stroke and has mild residual right-sided weakness. Serum creatinine is 0.9 mg/dL, and serum lactate dehydrogenase is elevated. Urine microscopy shows many RBCs. CT scan of the abdomen with contrast is performed showing a wedge-shaped right kidney. What is the most likely cause of this patient's symptoms?
> This patient, who has flank pain, hematuria, elevated lactate dehydrogenase (cell necrosis), and a wedge-shaped right kidney lesion on CT, likely has
, which results from interruption of the normal blood supply to the kidney. The most common cause of renal infraction is systemic
(from the left atrium or ventricle). The kidneys are more likely than other organs to suffer embolic infarctions as they are perfused at a higher rate (to support adequate glomerular filtration rate)
> Systemic thromboembolism commonly occurs with
atrial fibrillation (AF)
as the irregular heart contractions can lead to clot formation. AF, which can be paroxysmal (thereby going undiagnosed), may have also caused this patient's recent stroke, with emboli traveling to peripheral arteries in the brain. Systemic emboli can also occur following MI and endocarditis.
> The simultaneous development of stroke, intestinal or foot ischemia, and renal infarction should raise suspicion for embolic phenomena. These emboli may arise from left atrial or ventricular clots or valvular vegetations, among others.
Pulmonary hypertension can cause right heart failure (for pulmonate) and is sometimes associated with _________________, causing increased blood viscosity.
A life-threatening complication of lower extremity (LE) deep venous thrombus (DVT) is ________________________.
> LE DVT emboli reach the right heart via venous flow, enter the pulmonary circulation, and get caught in pulmonary artery branches. Rarely, when a communication exists between the right and left heart (eg, atrial or ventricular septal defect, patent foramen ovale), clots from the right heart may embolize to the brain and kidneys.
uWORLD: A 65 yo woman with Type 2 DM and HTN comes to the office for routine follow-up. She has occasional numbness in her feet. The patient takes ibuprofen for chronic back pain along with hctz, metformin, atorvastatin, and insulin deter. Her blood pressure is 120/76 mmHg supine and 122/80 mmHg standing. Laboratory evaluation shows a serum potassium level of 4.2 mEq/L and a creatinine level of 0.8 mg/dL. Urinalysis shows albuminuria. Lisinopril therapy is initiated. The next day, the patient returns due to lightheadedness and near-syncope. Her blood pressure is 102/66 mmHg supine and 80/45 mmHg standing. her pulse is 94/min. Cardiopulmonary examination is normal. Which of the following is most likely the major factor contributing to this patient's current symptoms?
> ACE inhibitors can cause significant first-dose hypertension in patients with volume depletion (eg. from diuretic use) or heart failure. To reduce the risk of first-dose hypertension, ACE inhibitor therapy should be initiated at low dosage.
> This patient with albuminuria was started on an
for treatment of early diabetic nephropathy. Although most patients remain asymptomatic with only a mild reduction in blood pressure,
can be a potential limiting factor with imitating ACE inhibitors. Significant hypotension is most likely to occur in patients with high plasma renin activity, such as those with
(eg. from diuretic use (HCTZ in this patient) or heart failure. Initation of ACE inhibitors therapy causes abrupt removal of the vasoconstrictive effects of angiotensin II, resulting in decreased peripheral vascular tone and a precipitous drop in blood pressure in susceptible patients. To prevent the development of first-dose hypertension, therapy should be started at low doses and slowly titrated upward as needed.
uWORLD: A 46 yo women dies in the hospital from respiratory failure after a prolonged illness. She had multiple comorbidities, including advanced renal disease. AAutospy revels multiple small, nondestructive masses attached to the edges of the mitral valve leaflet. Microscopy reveals that the masses are composed of platelet-rich thrombi, but cultures reveal no bacterial growth. Which of the following disease is most likely associated with this patient's condition?
> The autospy finding of sterile
attached to the mitral valve leaflets is characteristic of
nonbacterial thrombotic endocarditis
(NBTE). NBTE is most commonly associated with
, as well as chronic inflammatory disorders such as antiphopholipid syndrome, systemic lupus erythematous (Libman-Sacks endocarditis), and disseminated intravascular coagulation in patients with sepsis. NBTE is often seen in mucinous adenocarcinomas, which may relate to procoagulant effects of circulating mucin.
> The pathogenesis of NBTE is thought to begin with endothelial injury caused by circulating cytokines, which triggers platelet deposition in the presence of a hyper coagulable state. Compared to infective endocarditis, vegetations can easily dislodge and are more likely to embolize, causing infarction.
> Nonbacterial chromatic endocarditis is a form of noninfectious endocarditis characterized by deposition of sterile platelet thrombi on cardiac valves. It is commonly associated with advanced malignancy and can also occur with chronic inflammatory disorders (eg. antiphospholipid syndrome, systemic lupus erythematous) and sepsis.
uWORLD: An 85 yo man is transferred to the hospital from a nursing home for altered mental status and fever. Upon arrival, the patient is admitted directly to the intensive care unit with a presumptive diagnosis of septic shock. Antibiotic therapy is initiated. The patient is unable to provide any history, but his caretakers state that he has been having non-specific symptoms, including fever, for the past few days. The patient has a history of cardiovascular disease, diverticulitis, and dementia. His blood pressure is 60/40 mmHg despite aggressive intravenous hydration. Which of the following cellular changes occurs directly in response to norepinephrine therapy?
cAMP increase in cardiac muscle cell
> Norepinephrine stimulates cardiac beta1 adrenorecptors, which utilize the cAMP signal transduction pathway. Stimulation of these receptors by norepinephrine causes increases in cAMP concentration within cardiac myocytes.
uWORLD: A 56 yo Caucasian female presents to your office with chronic cough. She says that the cough is dry and affect quality of her life significantly. She denies chest pain, hemoptysis and SOB. Her past medical history is significant for long-standing hypertension, diabetes and MI experienced two months ago. She does not smoke or consume alcohol. Her blood pressure is 130/70 mmHg and heart rate is 70/min. Which of the following is the best next step in the management of this patient?
Careful review of current medications
> Cough is a very well recognized side effect of ACE inhibitor therapy. Cough secondary to ACE inhibitor therapy is characterized as dry, nonproductive, an d persistent.
> The mechanism behind ACE inhibitor induced cough is accumulation of bradykinin, substance P, or prostaglandins. Because angiotensin receptor blockers (ARBs) do not affect ACE activity, they theoretically should no cause cough.
uWORLD: A 60 yo man comes to the office fora routine follow-up visit. He feels well overall except for an intermittent, mild, generalized headache. The patient has no known medical problems and takes no medications. He does not smoke, follows a generally healthy diet, and exercises daily. On examination, his blood pressure is 150/85 mmHg, and he is started on lisinorpil. At a follow-up visit, the patient's blood pressure is 128/78 mmHg. He also has a dry cough that began a few weeks after starting lisinipril. This drug is stopped and losartan is now prescribed. The patient seems to be compliant with his medication; the cough resolves and he experiences no significant side effects. When compared with no treatment at all, this patient's current therapy is most likely to result in which of the following changes? (Renin, Angiotensin I, Angiotensin II, Aldosterone, Bradykinin)
Increase Angiotensin I
Increase Angiotensin II
No Change: Bradykinin
Angiotensin II receptor blockers
(ARBs) such as losartan competitively bind to angiotensin II receptors and block the effects of angiotensin II, resulting in
vascular smooth muscle relaxation
secretion. This reduces blood pressure, stimulating renal renin production, which in turn increases conversion of angiotensin I to angiotensin II. Because ACE function remains intact with the use of ARBs, bradykinin levels are not significantly affected. This is in contrast to ACE inhibitors, which lower angiotensin II and aldosterone levels but increases bradykinin levels. Bradykinin is thought to increase prostaglandin production, which induces coughing due to bronchial irritation.
> Angiotensin II receptor blockers (ARBs) work by blocking angiotensin II type 1 receptors, inhibiting the effects of angiotensin II. This results in arterial vasodilation and decreased aldosterone secretion. he resulting fall in blood pressure increases renin, angiotensin I, and angiotensin II levels. ARBs do not affect the activity of angiotensin-coveting enzyme, and therefore they do not affect bradykinin degradation and do not cause cough.
uWORLD: A 23 yo man comes to the office with chest discomfort that usually occurs during exercise,such as when jogging or climbing stairs. The symptoms go away 5 to 10 minutes after he stops. The patient has not had syncope but mentions some shortness of breath that accompanies the chest pain. Family History includes an uncle who died suddenly at the age of 35 years. Blood pressure is 122/70 mmHg and pulse is 70/min and regular. Apical impulse is strong and sustained. He has a soft crescendo-decrescendo systolic murmur at the apex and left sternal border while supine that becomes quite pronounced when he stands up. Which of the following medications should be avoided while treating this patient condition? (Amiodarone, disopyramide, Isosorbide dinitrate, Metoprolol, Verapamil)
> This patient's presentation, family history of premature sudden death, and systolic mummer that accentuates with standing from a supine position is consistent with hypertrophic cardiomyopathy (HCM). Patients with HCM have dynamic left ventricular outflow tract (LVOT) obstruction that worsens with decreased left ventricular (LV) volume (as can be caused by decreased preload and/or reduced systemic vascular resistance). As such, medications that generally should be
in patients with HCM include:
(eg dihydropyridine calcium channel blockers, nitroglycerin, and ACE inhibitors) decrease systemic vascular resistance, leading to decreased after load and lower LV volumes.
decrease LV venous filing (preload) and also result in greater outflow obstruction.
negative inotropic agents
such as beta blockers (metoprolol), nondihydropyridine calcium channel blockers (verapamil), and disopyramide
Reduce LVOT obstruction
and are helpful in symptomatic patients with HCM. In addition, beta blockers may also help reduce anginal symptoms by decreasing myocardial oxygen demand.
> The dynamic left ventricular (LV) outflow tract obstruction that occurs in hypertrophic cardiomyopathy worsens with decreased LV volume, which can be caused by education in cardiac preload and/or after load. Therefore, medications that decrease venous return or systemic vascular resistance (dihydropyridine calcium channel blockers, nitroglycerin) should generally be avoided.
uWORLD: A 53 yo man comes to the ED with SOB and chest tightness. The patient was palying in a poker tournament when his symptoms first began. He has a history of hypertension and is not compliant with his medications. His last medical follow up was a year ago. Blood pressure is 195/115 mmHg and pulse is 90/min and regular. Lung examination reveals bibasilar crackles. Nitroglycerin infusion is started and results in significant symptomatic improvement. Repeat blood pressure is 165/90 mmHg. Which of the following intracellular events is most likely responsible for the beneficial effects of this patient's treatment?
> Nitrates (via conversion to nitric oxide) activate guanylate cyclase and increase intracellular levels of cyclic guanosine monophosphate (cGMP). Increased levels of cGMP leads to myosin light-chain dephsophorylation, resulting in vascular smooth muscle relation.
> Increased levels of cGMP leads to
decreased intracellular calcium
(reduces the activity of myosin light-chain kinase) and activation of myosin light chain phosphatase. This promotes
myosin light-chain dephosphorylation
and vascular smooth muscle
uWORLD: A 67 yo man with nonischemic cardiomyopathy come to the office for follow-up. He recently was hospitalized for acute decompensated heart. The patient's symptoms have improved with multi drug treatment, but he has persistent shortness of breath on mild exertion. He has a history of hypertension and hypercholesterolemia. Blood pressure is 115/70 mmHg and pulse is 66/min. There is a third heart sound on heart auscultation and mild lower extremity pitting edema. A recent echocardiogram showed a left ventricular ejection fraction of 30%. Which of the following diuretics would most likely improve surivaal if added to this patient' current regimen? (Acetazolamide, furosemide, HCTZ, mannitol, spironolactone, triamterene)
> Mineralocorticoid receptor antagonists (eg. spironolactone, eplerenone) improve survival in patients with congestive heart failure and reduced left ventricular ejection fraction. They should not be used in patients with hyperkalemia or renal failure.
> Mineralocorticoid receptor antagonists (eg, spirolocatone, eplerenone) prevent aldosterone from binding to its receptor in the distal renal tubules. This leads to increased sodium and water excretion while conserving potassium ion
. These antagonists also block the deleterious effect of aldosterone on the heart, causing regression of myocardial fibrosis and
improvement in ventricular remodeling
> Mineralocorticoid receptor antagonists reduce morbidity and
in patients with congestive heart failure na decreased ejection fraction. Therefore, they are recommended in addition to standard heart failure therapy (ACE inhibitors and beta blockers)
> Acetazolamide (carbonic anhydrase inhibitor), HCTZ (thiazide diuretic), and triameterene (epithelial sodium channel blocker) have variably lower diuretic effect compared to loop diuretics and are not as efficacious for treating heart failure symptoms
> Furosemide is a loop diuretic frequently used for treatment of pulmonary congestion and fluid retention in heart failure patients. Although loop diuretics improve symptoms significantly, they do not provide survival benefit (ie. improved morbidity but not mortality) in these patients.
uWORLD: A 64 yo man comes to the office due to exertion chest pain over the last 6 months. He is a lifelong 1 pack per day cigarette smoker and has a history of type 2 diabetes mellitus and peripheral artery disease. This patient undergoes treadmill exercise stress testing and develops substernal chest pain on moderate exertion accompanied by ECG changes that resolve immediately upon rest. He refuses invasive cardiac testing. The patient is started on low-dose aspirin therapy for secondary prevention of cardiovascular disease but experiences shortness of breath and wheezing with the medication. Which of the following is the best alternate therapy for this patient? (Apixaban, cilostazol, clopidogrel, enoxaparin, eptifibatide, naproxen, warfarin)
> Clopidegrel irreversibly blocks the P2Y12 component of ADP receptors on the platelet surface and prevents platelet aggregation. Clopidogrel is as effective as aspirin in the prevention of cardiovascular events in patient s with coronary heart disease.
> This patient's clinical history is consistent with stable angina
due to underlying coronary heart disease (CHD). Patients with stable angina should be started on aspirin to decrease the risk of adverse cardiovascular events.
Aspirin impairs prostaglandin synthesis synthesis by irreversibly inhibiting cyclooxyrgenase (COX). Inhibition of COX-1 in platelets prevents synthesis of thromboxane A2, a potent stimulator of platelet aggregation and vasoconstriction.
This helps reduce the risk of occlusive thrombus formation and subsequent myocardial infarction.
> Some patients are unable tolerate aspirin due to exacerbation of preexisting respiratory symptoms (eg. rhinitis, asthma) or development of allergic reactions (eg. urticaria, angioedema, anaphylaxis). In these patients, alternate anti platelet agents should be used for prevention of cardiovascular events.
uWORLD: A 43 yo man comes to the ED with a 3 day history of persistent headaches. The patient has a past medical history of HTN but has had poor follow-up. Blood pressure is 224/1115 mmHg and pulse is 67/min. He appears middle confused during the physical examination, but no focal neurologic deficits are noted. Funduscopic examination shows bilateral papilledema. Serum creatinine is 1.4 mg/dL. The patient is started on an intravenous medication that causes arteriolar dilation, improves renal perfusion, and increases natriuresis. Repeat blood pressure an hour later is 182/92 mmHg with improvement of his symptoms. Which of the following agents is most likely being used in this patient? (Esmolol, Fenoldopam, Hydrazine, Nitroglycerin, phenylephrine)
is a short-acting, elective, peripheral
dopamine-1 receptor agonist
with little to no effect on alpha- or beta-adrenergic receptors. Dopamine-1 receptor stimulation activates adennylyl cyclase and raises intracellular cyclic AMP, resulting in vasodilation of most arterial beds with a corresponding decrease in systemic blood pressure.
is particularly prominent and leads to *increase renal perfusion, diuresis, and natriuresis. This makes fenoldopam especially beneficial in patients with acute kidney injury.
> Esmolol is a short-acting cardioselective beta-1 receptor antagonist. It works by reducing heart rate and myocardial contractility. Esmolol is not a vasodilator and does not increase renal perfusion.
> Hydrazine is a direct arteriolar vasodilator with no significant therapeutic effect on renal perfusion or natriuresis. It is not often in hypertensive emergency as it is associated wth reflex sympathetic activation, resulting in increased heart rate and contractility along with sodium and fluid retention.
> Nitroglycerin is a rapid-acting ventilator that decreases preload and cardiac output. It does NOT cause arterial dilation and does NOT improve renal perfusion. Nitroglycerin is primarily used to reduce myocardial oxygen demand in acute coronary syndrome.
> Phenylephrine is an alpha-adrenergic agonist that causes an increase in systemic vascular resistance due to arterial vasoconstriction. It is used in patients with hypotension or shock and is contraindicated in hypertensive emergency.
uWORLD: A 57 yo man dies 30 min after the onset of severe chest pain while driving to the ED. According to his wife, he had been complaining of intermittent short-lived episodes of chest pain recently. His past medical history was significant for hypertension, insulin-dependent type 2 diabetes mellitus, and hypercholesterolemia. The patient was not compliant with medication or follow-up. He had a strong family history of heart diseases and type 2 diabetes mellitus. An autospy is performed. Cross-section of the mid-right coronary artery is shown with occlusion. Which of the following is the most likely cause of death in the patient.
> Ventricular fibrillation is the most frequently mechanism of sudden cardiac death in the first 48 hours after acute myocardial infarction and is related to electrical instability in the ischemic myocardium.
> This patient's clinical presentation is suggestive of
coronary artery disease
(chest pain and multiple risk factors) causing an
acute myocardial infarction
(MI) due to thrombotic occlusion of the right coronary artery (RCA).
Sudden cardiac death (SCD)
refers to abrupt cessation of organized cardiac activity with hemodynamic collapse, causing an inability to maintain adequate tissue perfusion. SCD typically occurs due to malignant ventricular arrhythmias (sustained ventricular tachycardia/fibrillation), and it is related to coronary heart disease in approximately 70% of the patients.
Ventricular fibrillation (VF)
is the most frequent mechanism of SCD in the first 48 hours after acute MI and is released to electrical instability due to lack of perfusion in the ischemic myocardium.
> Atrial fibrillation (AF) can occur during acute MI; however, AF does not lead to SCD in such patients
> Systemic thromboembolism or embolic stroke can arise from left ventricular (LV) mural thrombus from an area of infarcted and akinetic myocardium. However, LV throbs typically takes several days to form and does not lead to SCD.
The ______________ corresponds to ventricular depolarization and phase 0 of the myocardial action potential. Class 1 C antiarrhythmic agents (flecainide) bind to fast sodium channels responsible for phase 0 depolarization, block the inward sodium current, and prolong QRS duration without affecting the QT interval
Class _________ antiarrhetmic drugs leads to increased action potential duration and QT interval prolongation.
Ex. Amiodarone, sotalol, dofetilide
block potassium channels
and inhabit the outward replacing current during phase 3 of the cardiac action potential.
uWORLD: A 64 yo Caucasian male presents with difficulty walking. He reports experiencing muscle cramps in his right thigh after walking about one block on level ground. the cramps subside quickly with rest. He has also recently noticed decreased sexual performance. The patient's medical history is significant for MI and carotid endarterectomy. Which of the following is the most likely cause of this patient's symptoms?
Lipid-filled intimal plaques
>This patient describes symptoms consistent with intermittent claudication (muscle pain with exercise that remits with rest). Claudication is almost always the result of atherosclerosis of larger named arteries. The obstruction of blood flow in these arteries result from fixed stenotic atheromatous lesson (Athermas are lipid-filled intimal plaques that budge into the arterial lumen). These stenoses prevent sufficient increase in blood flow to muscles during exercise, resulting in ischemic muscle pain. This pain is rapidly received by rest because the residual blog flow is adequate to meet the metabolic demands of resting, but not exercising muscle
> Intermittent muscle pain reproducibly caused by exercise and relived by a brief period of rest defines claudication. Claudication is almost always the result of atherosclerosis of larger, named arteries. The obstruction of blood flow in these arteries is the result of fixed stenotic lesions produced by atheroma, which are lipid-filled intimal plaques that bulge into the arterial lumen. The stenoses prevent sufficient increase in blood flow to exercising muscles, resulting in ischemic muscle pain.
Medial band-like calcifications occur in _______________________. It is condition characterized by calf iced deposits in muscular arteries. Typically individuals above 50 are affected. Though visible radiologically, and often times palpable on physical exam, these calcifications are clinically asymptomatic because they do not narrow the vessel lumen.
Monckeberg's medical calcific sclerosis (or medial calcinosis)
_________________________________ is a condition marked by homogenous deposition of hyaline eternal in the intimal and media of small arteries and arterioles. The underlying structure of the vessel wall is maintained, but the intimal is thickened and the arterial lumen narrowed. This lesion is usually a component of diabetic microangiopathy.
Onion-like concentric thickening of arteriolar walls due to laminated SMC and reduplicated basement membranes is seen in _________________________. It can result from malignant hypertension (diastolic pressures >120 mmHg). Although arterioles in all tissues may be affected, the kidneys, retinas, and intestinal arterioles are the areas most commonly affected. Muscles are less likely to be symptomatically involved.
Granulomatous inflammation of the media characterizes ___________________________, the most common form of systemic vasculitis in adults. Typically, this condition develops in patients above age 50, and causes headache, facial pain, jaw claudication, and visual loss.
temporal (giant cell) arteritis
uWORLD: A 52 yo Caucasian male present to your office complaining of periodic substernal chest pain that is precipitated by fast walking, especially uphill and against the wind. The pain remits following 5 minutes of rest. The patient has a history of hypertension and smokes one pack of cigarettes per day. This blood pressure is 140/80 mmHg and his pulse rate is 80 beats per minute. His lungs are clear to auscultation, and no heart murmurs are heard. There is no peripheral edema. Which of the following is the most likely pathogenetic mechanism of this patient's condition?
Atherosclerotic plaque obstructing 80% of the coronary artery lumen, no thrombus
> Fixed atherosceerlotic plaques obstructing > 75% of the lumen of the coronary artery are associated with stable anger. Plaques occluding less than 75% of the coronary artery lumen are tycpailly asymptomatic. Acute coronary syndromes (unable anger, myocardial infarction, and sudden cardiac death) result form acute plaque change, often with superimposed thrombosis. An ulcerated atherosclerotic plaque with a partially obstructive thrombus is associated with unstable angina or subendocardial infarction. A ruptured atherosclerotic plaque with a fully obstructive thrombus is associated with transmural myocardial infarction.
uWORLD: Atherosclerotic lesions involving the coronary arteries limit blood flow to portions of the myocardium supplied by the affected vessels. The administration of certain medication can cause a redistrubtion of blood flow away from ischemic areas, exacerbating existing myocardial ischemia. A drug that causes which of the following effects is most likely to be associated with this phenomenon?
Coronary arteriolar dilation
> In coronary artery disease, coronary vessel occlusion can be bypassed by the natural existence of compensatory recruitment of collateral vessels that help support blood flow. These collateral micro vessels from a network of passageways between major vessels, allowing supplemental blood flow to myocardium distal to an occluded vessel. In the presence of myocardial ischemia, coronary arterioles vasodilator in response to local mediators, diverting collateral blood flow to ischemic areas. Thus, collateral circulation helps to alleviate ischemia and preserve myocardial function.
Drugs such as adenosine and dipyridamole and selective vasodilators of coronary vessels. When myocardial ischemia is present, these drugs cause a redistribution of blood flow through the collateral micro vessels and coronary arterioles that can reduce collateral blood flow. Arterioles within ischemic areas are already maximally dilated prior to drug administration. However, use of these agents cause vasodilation of canary arterioles in nonischemic regions. This leads to decreased perfusion pressure within the collateral micro vessels supplying the ischemic myocardium, diverting blood flow from ischemic areas to nonischemic areas. This phenomena, known as coronary steal, may lead to hypo perfusion and potential worsening of existing ischemia.
> Collateral micro vessels from adjacent pathways for blood flow to areas distal to an occluded vessel. Adenosine and dipyridamole are selective vasodilators of canary vessels that can cause coronary steal, a phenomenon in which blood flow in ischemic ares is reduced due to arteriolar vasodilation in nonischemic areas. Coronary steal can lead to hypo perfusion and worsening of existing ischemia.
uWORLD: A 82 yo man is brought to the ED after a syncopal episode. He has no chest pain or dyspnea but has severe consitpation of recent onset. He was hospitalized 2 weeks ago for atrial fibrillation with rapid ventricular response and was discharged home with oral medications after appropriate management. His past medical history is also significant for hypertension and severe chronic obstructive pulmonary disease requiring oxygen therapy. His blood pressure is 105/60 mmHg and pulse is 50/min. Examination reveals bilateral decreased breath sounds and normal heart sounds. ECG shows new-onset second-degree atrioventricular block. Which of he following drugs is most likely cause of this current condition
> Common side effects of nondihydropyridine calcium channel blockers (eg. dilitizaem, verapamil) include constipation, bradycardia, atrioventricular conduction block (negative chronotropic effect), and worsening of heart failure in patients with reduced left ventricular function (negative inotropic effect)
> Beta blockers (BBs) are commonly used used for heart rate control in patients with AF and can cause or worsen AV block. Nonselective BBs (propranolol) impair bronchodilation and are contraindicated in patients with asthma and/or severe chronic obstructive pulmonary disease.. In addition, constipation is not a significant side effect of BB therapy.
> This patent's presentation (constipation, new-onset second-degree atrioventricular [AV] block, and syncope) in the setting of new medication use
(AF) is likely due to calcium channel blocker (CCB) therapy.
are nondihydrophyridine CCBs that are frequently used for hypertension, angina pectoris, and supra ventricular arrhythmias (atrial flutter, AF, paroxysmal supraventircular tachycardia).
> These drugs exert their primary action by blocking the
L-type calcium channels
, thereby decreasing phase 0 depolarization and conduction velocity in the sinoatiral and AV nodes. This leads to
slowing of the sinus rate
and conduction through the AV node, which can then cause bradycardia and varying degrees of AV block. The drugs also have a
negative inotropic effect
and are relatively contraindicated in patients with congestive heart failure due to left ventricular systolic dysfunction.
is a major side effect nondihydropyridines CCBs (verapamil > diltiazem)
uWORLD: A 56 yo man comes to the clinic for a routine check-up. Past medical history includes hypertension, type 2 diabetes mellitus, hyperlipidemia, and mild intermittent asthma. The patient currently takes no medications and has not seen a physician in 7 years. He reports feeling well overall. His blood pressure 152/101 mmHg and pulse is 87/min. Waist circumference is 110 cm (43 inches). Laboratory studies are as follows:
LDL: 161 mg/dL
Fasting blood glucose: 201 mg/dL
Which of the following vascular beds is most likely to carry the highest atheroscerlotic burden in this patient?
> Atherosclerosis is pathologic process involving the arterial walls and affect all major vascular beds including coronary, cerebral, and peripheral arteries. The lower abdominal aorta and coronary arteries develop the highest burden of atherosclerosis.
> Of all the major vascular beds, the
lower abdominal aorta
are the most susceptible to atherosclerosis.
uWORLD: A 33 yo woman who recently immigrated to the US is brought to ED with severe shortness of breath and hemoptysis. Physical examination reveals a diastolic mummer. Chest x-ray shows severe pulmonary vascular congestion and edema. She is admitted to the hospital, treated with diuretics, and begins to feel better. However, during her hospitalization, she develops right-sided hemiparesis. Which of the following additional findings in this patient would be most suggestive of combined disease involving the mitral and aortic valves rather than exclusive mitral involvement?
Increased left ventricular diastolic pressure
> Isolated mitral stenosis elevates left atrial diastolic pressure can can therefore cause elevated pulmonary capillary wedge pressure, pulmonary hypertension, decreased vascular compliance, right ventricular dilation, and functional tricuspid regurgitation.
Diastolic pressure in the left ventricle is usually near normal or even decreased with severe mitral stenosis.
> Rheumatic heart disease almost always affects the mitral valve, but both the mitral and aortic valves are affected in about 25% of cases. Rheumatic heart disease typically causes combined aortic stenosis and regurgitation, both of which can increase LV diastolic pressure.
uWORLD: A 38 yo Caucasian female presents to your office for a routine check-up, and requests a simple and reliable method of contraception. She remarks, "I have already had three children. I would not like to have more any time soon. Do you think I can start on birth control pill?". She had no significant past medical history, and does not take any medications other than a daily multivitamin. Her family isotropy is significant for stroke in her mother and type 2 diabetes mellitus in her father. Which of the following factors would most affect your decision to prescribe oral contraceptives to this patient? (diet, physical activity level, smoking status, parity, glucose intolerance, serum HDL levels).
> The risk of cardiovascular events due to oral contraceptive pills is increased in smokers and patient over the age of 35. In particular, individuals who smoke more than 15 cigarettes per day have a much higher incidence of cardiovascular events.
> The absolute contraindications to the use of OCPS are:
1) Prior history of thromboembolic event or stroke.
2) History of an estrogen-dependent tumor
3) Women over age 35 years who smoke heavily
5) Decompensated or active liver disease (would impair steroid metabolism)
uWORLD: A 42 yo man is found dead at home. His medical problems include HTN and dyslipidemia, but he had been noncompliant with his medications. The patient had a lengthy smoking history and, despite constant urging from his physicians to stop smoking, he hard only quit recently. An autospy is requested by the family. Pathoglocial examination shows complete thrombotic occlusion of the left main coronary artery and diffuse atherosclerotic vascular disease characterized by multiple atheroma. Along with a lipid core, these atheroma have a fibrous cap formed from dense deposition of collagen. Which of the following cells are directly responsible for synthesizing the fibrous cap?
Smooth muscle cells
> Vascular smooth muscle cells (VSMCs) are the only cells within the atherosclerotic plaque capable of synthesizing structurally important collagen isoforms and other matrix components. Progressive enlargement of the plaque results in remodeling of the extracellular matrix and VSMC death, promoting development of vulnerable plaques with an increased propensity for rupture.
> Fibroblasts are found infrequently in the tunica intimal of blood vessels and are not significantly involved in atherosclerosis pathogenesis.
> Activated macrophages and T lymphocyte secrete growth factors that recruit the VSMCs responsible for forming the fibrous cap, but they are not directly responsible for he dense deposition of fibrillar collagen. Macrophages also produce matrix metalloproteinases and tissue factors that degrade that extracellular matrix, causing the formation of large, soft lipid-rich core with thinning of the fibrous cap. Such vulnerable plaques have an increased propensity for rupture.
uWORLD: A 30 yo Asian male with external calf pain and painful foot ulcers demonstrates hypersensitivity to intradermally injected tobacco extract. Which pathologic processes is most likely responsible for this patient's condition?
Segmental vasculitis extending into contiguous veins and nerves
> This patient has distal lower extremity vascular insufficiency, and is presumably a heavy smoker who has therefore developed immune hypersensitivity to a component of tobacco smoke. The most likely diagnosis is thromboangiitis obliterates (Bueger's disease), a vasculitis of medium and small-sized arteries, principally the tibial and rail arteries.
> This condition may result from direct endothelial cell toxicity from tobacco products or from hypersensitivity to them.
> Thromboangiitis obliterates (Buerger's disease) is usually seen among heavy cigarette smokers with onset before age 35, and is associated with hypersensitivity to intradermal injections of tobacco extracts. This segmental thrombosing vasculitis often extends into contiguous veins and nerves, encasing them in fibrous tissue.
___________________ predisposes to the formation thoracic aortic aneurysms with an increased risk of aortic dissection. It can also cause dilation of the aortic root leading to aortic regurgitation.
Cystic medial necrosis
A 40 yo Caucasian male dies in a motor vehicle accident. He had been a one pack-per-day cigarette smoker, and was moderately overweight. His family history is significant for a myocardial infarction in his father at age 48, and a stroke in his mother at 58. Which of the following vessels is most likely to show atherosclerotic involvement in this patient at autospy?
> Atherosclerotic plaques develop predominantly in large elastic arteries (eg aorta, carotid, and iliac arteries), and in large or medium-sized muscular arteries (eg coronary and popliteal arteries). In humans, the
is the vessel most heavily involved with lesions most prominent around the ostia of major material branches. After the abdominal aorta, the next most heavily involved vessels are (in decreasing order order)"
the coronary arteries, the popliteal arteries
, the internal carotids, and the circle of Willis. The upper limb arteries are usually spared. The mesenteric and renal arteries tend to be spared except at their ostia (openings from the aorta)
A 57-yo Caucasian male is hospitalized with muscle pain, fatigue and dark urine. His past medical history is significant for stable angina. The patent's medications include metoprolol, atorvastatin, and aspirin. Laboratory evaluations reveals that he is in acute renal failure. The addition of which of the following medications is most likely to have precipitated this patient's condition? (Erythromycin, phenytoin, rifampin, griseofulvin, phenobarbitone)
> Most statins are metabolized by cytochrome P-450 3A4, with exception of pravastatin. Concomitant administration of drugs that inhibit statin metabolism (e.g. macrocodes) is associated with increased incidence of statin-induced myopathy and rhabdomyolysis. Acute renal failure is a possible sequela of rhabdomyolysis.
> Statins are very effective agents in the reduction of LDL cholesterol. Serious side effects of statins include myopathy and hepatitis. Myopathy is a rare complication of statin use, clinically defined as muscle pain with serum creatine kinase over 10 times the upper limit of normal. With the exception of pravastatin, the statin drugs (simvastatin, lovastatin, atorvastatin) are metabolized by the liver cytorhome P-450 3A4.
> Erthryomycin inhibits cytochrome 3A4. Thus, concurrent use of erythromycin with these drugs causes increased serum levels of statin, which is in turn associated with increased risk for myopathy. (Other inhibitors of cytochrome P450 3A4 include keoconzole, cyclosporine, HIV protease inhibitors, and grapefruit juice).
If a patient is on an agent act inhibits cytochrome P-450 3A4, pravastatin is the statin of choice.
> Phenytoin, rifampin, griseofulvin and phenobarbitone are cytochrome P-450 inducers. Thus, the addition of these agents would reduce the plasma concentration of drugs metabolized via the cytochrome P-450 pathway.
A 60 yo man comes to the physician with a 6 month history of exertional chest pain that remits with rest. His other medical problems include HTN, DM, and hypercholesterolemia. An exercise stress test is positive for inducible ischemia. Cardiac cauterization shows 80% occlusion of the right coronary artery and 60% occlusion of the left coronary artery. The first step in the pathogenesis of this patient's coronary disease most likely involved which of the following cell types?
>This patient's presentation is consistent with coronary artery atherosclerosis. The pathogenesis of atherosclerosis is thought to begin with endothelial cell injury. In the response-to-injury model, chronic endothelial cell injury may result from HTN (and related hemodynamic factors), hyperlipidemia, smoking, diabetes, homocysteine, toxins (including alcohol), viruses, and/or immune reactions. Such injury results in endothelial cell dysfunction and/or exposure of sub endothelial collagen (endothelial cell denudation)
> Endothelial cell dysfunction results in increased permeability as well as monocyte and lymphocyte adhesion and migration into the initima. Endothelial denudation and exposure of sub endothelial collagen promote
. Growth factors produced by monocytes and platelets stimulate medial
smooth muscle cell (SMC) migration
into and proliferation in the intimal. At the same time
increased endothelial cell permeability allows LDL cholesterol into the intimal
, where it is phagocytosed by the accumulating macrophages and SMCs to produce foam cells.
> Atherosclerosis is initiated by receptive endothelial cell injury, which leads to a chronic inflammatory state in the underlying intimal of large elastic arteries as well as large and medium-size muscular arteries.
uWORLD: A 34 yo woman comes to the ED because of sharp chest pain that radiates to the left shoulder. The pain increases with inspiration and is partially received by sitting up and leaning forwards. Review of her outpatient medical records shows that she was seen for a facial rash 6 months ago. She is also being evaluated for proteinuria that was identified during her last clinic appointment. Which of the following is the most likely cause of this patient's chest pain?
> The patient's chest pain is characteristic of
, which along with her facial rash and proteinuria is suggestive of underlying
systemic lupus erthematosus (SLE).
SLE is a chronic autoimmune disease predominantly affecting women age 20-40 that causes
is common in SLE and most often manifests as plueritis or pericarditis.
> Pericarditis presents with severe and constant middle or left chest pain that may radiate to the neck and shoulders (particularly the trapezius ridge). The pain increases on inspiration (pleuritic) and is relieved by
sitting up and leaning forward
(postural). Auscultation of the chest reveals a scratchy sound called a
pericardial friction rub
that is beset heard when the patient is leaning forward or lying prone. Additional cardiovascular manifestiaotns in SLE include pericardial effusion, verrucosus (Libman-Sacks) endocarditis, and increased risk of coronary artery disease.
> Cardiac tamponade is caused by accumulation of fluid in the pericardial space that prevents the heart from filling proper in diastole. It presents with dyspnea and tachypnea. Physical examination shows distended neck veins, hypotension, diminished heart sounds, and pulses paradoxus (drop in systolic blood pressure >10 mmHg on inspiration) .
uWORLD: A 67 yo Caucasian male with past medical history significant for severe, ongoing drug-resistant HTN, dies of intracranial hemorrhage. At autospy, the right kidney is significantly shrunken, though the left kidney appears grossly normal. Which of the colloing mechanism most likely explains the renal morphology in this patient?
oxygen and nutrient deprivation
> The pathogenesis of this patient's HTN and ultimate intracranial hemorrhage i most likely renovascular, specially unilateral renal artery stenosis. The most common cause of renal artery stenosis (70% of cases) is obstruction by an atheromatous plaque at the origin of the renal artery. This lesion occurs more frequently in males and patients with diabetes mellitus, and incidence
The ischemic kidney secretes high levels of renin, causing the HTN. Eventually, the stenosis may also cause renal atrophy due to oxygen and nutrient deprivation.
> On histoloigc exam, the atrophic kidney shows crowded glomeruli, tubulointersitial atrophy and fibrosis, and oftentimes focal inflammatory infiltrates.
Epinephrine increases systolic blood pressure (alpha1 + beta1) and heart rate (beta1), and either increases or decreases diastolic blood pressure spending on the dose (either alpha1 or beta2 predominates). Pretreatment with _____________________ eliminates the beta effect of epinephrine (vasodilation and tachycardia),
leaving only the alpha effect (vasoconstriction).
uWORLD: 78 yo male nursing home resident with severe dementia is brought to the ED due to a one day history of lethargy, fever and vomiting. His caregivers report that he has had poor oral intake over the last week. His past medical history is significant for emphysema, CHF with reduced left ventricular systolic function, HTN, and DM Type 2. On physical examination, he is lethargic but arousable. His blood pressure is 60/30 mmHg mmHg, and his heart rate is 120/min and regular. His extremities are warm. Coarse rhonchi are heard over the right lower lung field. After receiving several intravenous fluid boluses, he is given an intravenous infusion of an agent that increases peripheral vascular resistance, increases systolic blood pressure, decreases pulse pressure, and decreases heart rate. Which of he following agents is being described (phenylephrine, Dobutamine, isoproterenol, isoproterenol, epinephrine, clonidine)
> Phenylephrine is a selective alpha-1 adrenergic receptor agonist that causes marked arterial vasoconstriction when administered intravenously. The result is an increase in systemic vascular resistance and blood pressure. The induced blood pressure increase elicits a barorecptor-meidated increase in vagal tone, which results in decreased stroke volume and a slowed heart rate. The pulse pressure, defined as the systolic pressure minus the diastolic pressure, is decreased by phenylephrine because of the reflex decrease in stroke volume and increased after load.
> Isoproterenol is a nonselective beta-adrenergic agonist. It decreases peripheral vascular resistance and diastolic blood pressure and increases the cardiac rate and output as well as the pulse pressure.
uWORLD: A 62 yo woman comes to the physician becomes a vague feeling of heaviness in her legs, especially when standing still for long periods. Her the remedial problems include osteoarthritis and gastroesophageal reflux disease. She has worked as a cashier at a local department store for the last 20 years. Physical examination shows dilate and tortuous superficial veins in her lower legs. This patient's condition is most likely to be complicated by which of the following? (Intermittent claduicaiton, ischemic stroke, MI, Phelgmasia alba-doyens, pulmonary embolism, skin ulcerations)
> Common complications resulting from poor blood flow include painful thromboses, stasis dermatitis,
, poor wound healing, and superficial infections
> Varicose veins are dilated, torturous veins resulting form impairment of the venous valves and reflux of venous blood. This leads to venous stasis/congestion, edema, and an increased incidence of superficial venous thrombosis. Thromboembolism is a very infrequent complication of varicose veins, while venous stasis ulcers are very common and often occur over the medial malleolus.
> ALTHOUGH deep venous thrones are the leading cause of pulmonary emboli, varicose vein thromboses are restricted to the superficial venous system. Thromboembolism therefore occurs very infrequently with varicose veins.
uWORLD: A 64 yo male is brought to the ED with severe chest pain, diaphoresis and mild shortness of breath. Following the intimal evaluation, the patient is taken to the cardiac cauterization lab and near-total occlusion of the left anterior descending (LAD) coronary artery is detected. The vascular endothelium secretes which of the following substances to inhibit platelet aggregation:
(Thromboxane A2, serotonin, Hageman Factor, Kallikrein, Protein C, Prostacyclin)
> Proastacyclin synthase in the capillary endothelium synthesizes prostacyclin from prostaglandin H2. Prostacyclin inhibits platelet aggregation and adhesion to the vascular endothelium, and also vasodilators, increases vascular permeability, and stimulate leukocyte chemotaxis.
> Normally, prostacyclin exists in dynamic balance with thromboxane A2 (TXA2), a prostaglandin that enhances platelet aggregation and causes vasoconstriction.
> Damaged endothelial cells lose the ability to synthesize prostacyclin, and therefore predisposes to the development of thrombi and hemostasis. Synthetic prostacyclin is used in the treatment of pulmonary hypertension, peripheral vascular disease and Raynaud syndrome
__________________ is converted into bradykinin Bradykinin is normally degraded by angiotensin covering enzyme (ACE), and is responsible for the cough seen with ACE inhibitors
-> Converted by the enzyme kallikrein
________________________ is synthesized by the liver and is activated by collagen exposed when the vascular basement membrane is damaged. It participate in activation of the intrinsic clotting pathway and activation of fibrinolysis.
Hagman fact (Factor XII of the clotting cascade)
uWORLD: A 35 yo man comes to the office with progressive fatigue, dyspnea on exertion, and lower extremity edema over the last 2 weeks. Preceding these symptoms, he had a episode of fever, runny nose, an myalgia that resolved in several days. The patient has no the rmeidcal history, takes no medications, and has no significant family history. He occasionally drinks alcohol and does not use tobacco. His blood pressure is 112/74 mmHg, and pulse is 98/min and regular. Physical examination reveals jugular venous distention, bibasilar crackles on lung auscultation, and 2+ pitting edema involving the lower extremities. Which of the following echocardiographic findings is most likely to be seen in this patient?
Dilated ventricles with abnormal systolic ventricular function
> This patient presents with sings of both left (bibasilar crackles) and right (eg, jugular venous distention, peripheral edema)
decompensated heart failure
. The progressive onset of heart failure in the setting of a recent viral infection (eg. fever, rhinorrhea, myalgia) should raise suspicion for
> Dilated cardiomyopathy in this setting results from direct viral injury as well as an autoimmune reaction to virally altered myocytes.
> Myocardial inflammation leads to dilation and enlargement of the heart chambers (eccentric hypertrophy) with decreased ventricular contractility (systolic dysfunction). Other cases of dilated cardiomyopathy include genetics (familial), toxicity (eg. alcoholism), pregnancy (permpartum), and hemochromatosis
________________________ is more suggestive of ischemic heart disease (eg. MI) as contraction is impaired in the damaged portion of the myocardium. Regional myocardial dysfunction causes volume overload for the remaining viable myocardium. The net result is usually eccentric hypertrophy with enlargement of the left ventricular cavity.
Regional wall motion abnormality
uWORLD: A 56 yo man comes to the ED with acute onset of chest pain and dyspnea. The pain started earlier in the day, has been significantly worsening over the past few hours, and is associated with difficulty catching his breath. His other medical problems include HTN and gastroesophgeal reflux disease. He has not had previous surgeries. Ventilation-perfusion (V/Q( scan reveals a large perfusion defect that does not match a ventilation defect in the lungs. This patient's condition is most likely the result of which of the following?
Deep vein thrombosis
> This patient presents with acute-onset chest pain and dyspnea and an abnormal V/Q scan consistent with likely pulmonary embolism (PE). A perfusion defect that is not anatomically matched by a ventilation defect (i.e. mismatched defect) indicates that blood flow has been occluded to that segment of the lung. A ventilation defect anatomically matched by a perfusion defect (i.e, matched defect) usually indicates lung collapse or consolidation. Deep vein thrombosis (DVT) is the most common cause of PE and is part of a continuum of the same disease, which is known as pulmonary thrmobembolism.
A significant mismatch defect on ventilation-perfusion scan is a specific finding for a pulmonary embolism, which is usually the result of a deep vein thrombosis and part of a continuum of the same disease, known as pulmonary thromboembolism.
uWORLD: A 58 yo man with dyspnea and chronic exertion anger is elevated for coronary revascularization. He has a history of hypertension, type 2 diabetes mellitus, and hypercholesterolemia. His blood pressure is 130/80 mmHg and pulse is 72/min and regular. Cardiopulmonary examination is normal with the exception of a fourth heart sound. Echocardiogram reveals hypokinesia of the anterior wall of the left ventricle and a left ventricular ejection fraction (LVEF) of 35%. The patient undergoes coronary artery bypass grafting. Repeat echocardiogram 10 days after the surgery shows that hypokinesia is no longer evident and LVEF has increased to 50%. Which of the following best explains the changes in the cardiac contractility and wall motion seen in this patient?
refers to a state of
chronic myocardial ischemia
in which both myocardial metabolism and function are reduced to match a concomitant reduction in coronary blood flow (due to moderate/severe flow-limiting stenosis). This new equilibrium prevents myocardial necrosis. Chronically hibernating myocardium demonstrates decreased expression and disorganization of contractile and cytoskeletal proteins, altered adrenergic control, and reduced calcium responsiveness. The changes lead to
and let ventricular (LV) systolic dysfunction. However, coronary revascularization and subsequent restoration of blood flow to hibernating myocardium improves contractility and LV function.
> Hibernating myocardium refers tot he presence of left ventricular systolic dysfunction due to reduced coronary blood flow at rest that is partially or completely reversible by coronary revascularization .
uWORLD: A 62 yo man with a long history of HTN comes to the physician for routine physical examination. His blood pressure is 150/90 mmHg and hear rate is 74/min and regular. Cardiac auscultation shows a pre systolic sound that immediately precedes the first heart sound and is best heard during expiration when the patient is lying on his left side. Chest x-ray reveals extensive calcifications around the mitral and aortic valves. Which of the following is the most likely explanation for the additional heart sound.
Increased stiffness of the left ventricular wall
> This patient has a
fourth heart sound (S4)
that is most likely caused by extensive left ventricular hypertrophy due to long-standing hypertension (hypertensive heart disease).
> The S4 heart sound is a sign of
It occurs when there is a sudden rise in end-diastolic ventricular pressure caused by
against a ventricle that has reached its elastic limit. An S4 may be present in any condition that causes
Reduced ventricular compliance
(eg, hypertensive heart disease, aortic stenosis, hypertrophic cardiomyopathy). It is heard as a
low-frequency late diastolic sound
that occurs just prior to the first heart sound (S1) after the onset of the P wave on ECG (coinciding with the active phase of ventricular filling). A left-sided S4 is but heard with the bell of the stethoscope over the cardiac apex with the patient in the left lateral decubitus position; it will intensify during expiration due to increased blood flow from the lungs to the left atrium.
A 56-yo man comes to the cardiology clinic because of fatigue, palatpiations, and external dyspnea over the last several weeks. On physical examination, his heart rate is irregular and measures 122 BPM, while his blood pressure is 110/70 mmHg. The patient undergoes further work-up, including ECG, radiographic studies, and laboratory studies. His ECG shows atrial fibrillation and trans-esophageal echocardiogprahy reveals a thrombus in a dilated left atrium. In the even of an interruption of blood flow secondary to arterial occlusion, which of the following organs would be least vulnerable to infarction? (spleen, brain, kidney, liver, heart)
> Organ susceptiblity to infraction after occlusion of a feeding artery is ranked form greatest to least as follows: CNS, myocardium, kindly, spleen, and liver. The presence of a dual and/or collateral blood supply (as seen in the liver, which is supplied by the hepatic artery and portal vein) enables an organ to tolerate arterial occlusion better than those with end-arterial circulations.
uWORLD: A 46 yo man is diagnosed with resistant HTN. He had a comprehensive workup for secondary hypertension, which was unrevealing. The patient has tried multiple antiherytensive megatons without significant effect. Past medical history is otherwise unremarkable. He agrees to enroll in a trial of a new long-acting medication that causes selective direct relaxation of the smooth muscle of arterioles but does not affect the veins. Which of the following adverse effects is most likely to be caused by the drug during the clinical trial? (Angioedema, bradycardia, cold extremities, decreased cardiac output , prescient cough, sodium and fluid retention transient hypertension.
Sodium and fluid retention
> Selective arteriolar vasodilators (eg, hydrazine, minoxidil) lower blood pressure by reducing systemic vascular resistance. However, this effect is limited by subsequent stimulation of baroreceptors with resulting reflex
. This leads to increased heart rate, contractility, and cardiac output. In addition, sympathetic stimulation of the
axis results in
sodium and fluid retention
with peripheral edema. These effects offset much of the blood pressure lowering effect of these drugs and limit their long-term efficiency.
> These agents are rarely used as mono therapy for chronic magnament of hypertension. However, they are useful actually for patients with severely elevated blood pressure. They can also be given in combination with sympatholytics and diuretics to mitigate the side effects and provide synergistic blood pressure lowering in patients with resistant hypertension.
_________________ decrease cardiac output, leading to
peripheral vasoconstriction and resulting in cold hands and feet
However, direct arteriolar vasodilators enhance blood flow to peripheral tissues, including skin and muscle, and they can be used to relieve symptoms in patients with Raynaud phenomenon.
uWORLD: A 36 yo man comes to the office after he was found to have an abnormal lipid panel during employee wellness testing at his company. He has no prior medical problems and takes no medications. The patient is a software technical and has a sedentary lifestyle. he eats mostly fast foods, rarely exercises, and drinks 2-3 cans of beer daily. His BMI is 31 kg/m2. Physical examination is unremarkable. Results of laboratory studies performed in the office are as follows:
Total cholesterol: 290 mg/dL
High-Density lipoprotein: 45 mg/dL
Low-Density lipoprotein: 110 mg/dL
Triglycerides: 675 mg/dL
Lifestyle modification with a balanced diet, regular exercise, and reduced alcohol intake is advised. He is also started on fenofibrate therapy. This medication is most likely to help the patient by which of the following mechanism?
Reducing hepatic VLDL production
Lipoprotein lipase (LPL)
hydrolyzes triglycerides in chylomicrons and VLDL to release free fatty acids, which can be used for energy or converted back to triglycerides for storage in adipose tissue. It also facilitates the transfer of triglycerides from those lipoproteins to HDL.
Fibrates (eg. gemfibrozil, fenofibrate) activate
peroxisome proliferator-activated receptor alpha (PPAR-alpha), which leads to
decreased hepatic VLDL
production and increased LPL activity. They are able to decrease triglyceride levels by 25-50% and increase HDL by 5%-20%.
> Fish oil supplements containing high concentrations of
omega-3 fatty acids also decrease
VLDL production*, and inhibit synthesis of apolipoprotein B as well. These supplements lower triglycerides and can be used as an alternate treatment for patients with moderate hypertriglyceridemia.
uWORLD: A 53- yo man comes to the physician with progressive exertion dyspnea. He has smoked 2 packs of cigars per day for the last 35 years. Physical examination shows increased anteroposterior diameter of his chest. Auscultation reveals decreased breath sounds and scattered wheezes throughout this lungs. Examination of his extremities is unremarkable. An echocardiogram shows moderate dilatation of the right ventricle and increased central venous pressure. The absence of peripheral edema in this patient is best explained by which of the following compensatory mechanism?
> The patient's heavy smoking history, progressive exertion dyspnea, and physical examination findings are suggestive of chronic obstructive pulmonary disease (COPD) caused by choleric bronchitis/emphysema. In addition, his right ventricular dilation and elevated central venous pressure are indicative of for pulmonate secondary to COPD. The increased central venous pressure predisposes him to developing noninflammatory edema. This condition is characterized by excess accumulation of tranduative fluid in the interstitial tissues and occurs in the following conditions:
1) Elevated capillary hydrostatic pressure - via arteriolar dilation (eg. use of dihydropyridine calcium channel blockers)
2) Decrease plasma oncotic pressure - via decrease albumin levels via nephrotic syndrome, severe liver disease, and malnutrition
3) Sodium and water retention - via acute kidney injury, chronic kidney disease, and CHF.
4) Lymphatic obstruction causes edema by impairing the removal of excess interstitial fluid. Common causes of lymphatic obstruction include filariasis, invasive malignancies, etc.
> Moderate increase in capillary fluid transduction can be offset by a
compensatory increase in tissue lymphatic drainage that occurs due to increase interstitial fluid pressure
. Clinically apparent edema appears only when net plasma filtration has risen sufficiently to overwhelm the resorptive capacity of the tissue lymphatics.
_________________ leads to a decrescendo diastolic mummer that begins immediately after A2 (aortic opponent of second heart sound). The mummer is high-pitched, blowing in quality and best heard along the left sternal border at the third and fourth intercostal spaces while the patient is sitting up and leaning forward with his breath held at end-expiration.
of an ___________ murmur occurs immediately after the
aortic valve closure
, when the pressure gradient between the aorta and the left ventricle is at its maximum
uWORLD: A 71 yo woman comes to the ED due to progressive dyspnea and orthopnea of the last week. She has a history of MI and systolic heart failure with a left ventricular ejection fraction of 15%. The patient is compliant with her medications, which include carvedilol. furosemide, aspirin, lisinopril, and aotrvastatin. Blood pressure is 118/74 mmHg and pulse is 72/min. Examination reveals elevated jaguars venous pressure, bibasilar crackles, and S3 heart sound, and bilateral lower extremity pitting edema. The patient is started on dobutamine infusion, which provides significant symptom relief. Echocardiogram shows mild improvement in cardiac contractility. Which of the following is the likely mechanism underlying the patient's clinical improvement?
Gs protein-adenylate cyclase activation
> Dkobtuamine is a beta-adrenergic agonist with predominant activity on beta1-recetors and weak activity on beta2 and alpha 1 receptors. Stimulation of beta 1 receptors lead to an increased production of cAMP and increased cytosolic Ca2+ concentrations. This facilitates the interaction between actin and myosin, resulting in increased myocardial contractility.
> In the vasculature, alpha1 against activity (vasoconstriction) balances the beta2 agonist effect (vasodilation) with a resultant mild vasodilation. The net hemodynamic effects are an increase in cardiac contractility and a decrease in systemic vascular resistance without significant change in arterial blood pressure. The increase in CO can improve symptoms and end-organ perfusion in patients with severe left ventricular systolic dysfunction and cariogenic shock.
________________________ increase the intracellular levels of cAMP by preventing its enzymatic breakdown in cardiac and vascular tissues, and result in
positive inotropic effects
Phosphodiesterase inhibitors (eg, milrinone)
______________ is an anti-anginas drug that inhibits late-phase inward sodium channels in ischemic myocardial cells during cardiac repolarization. A decrease in intracellular sodium concentration enhances calcium efflux via the sodium-calcium exchanger, which reduces myocardial oxygen consumption.
_____________ acts by inhibiting the sodium-potassium ATPase pump. This increases intracellular sodium concentration, which in turn decrease activity of the sodium-calcium exchanger that exports calcium from myocardial cells. The corresponding rise in intracellular Ca2+ concentration leads to improved myocardial contractility
uWORLD: A 43 yo woman comes to the office due to occasional chest discomfort over the last year. She describes the pain as a mid-line pressure or squeezing sensation that lasts 10-15 minutes and is sometimes accompanied by diaphoresis. The patient has no history of HTN or DM but is an active smoker. Exercise stress testing shows good exercise capacity with no ischemic signs of symptoms. Ambulatory ECG monitoring shows transient ST-segment elevations in leads I, aVL, and V1-V4 during an episode of chest pain at night. Which of the following would most likely provoke this patient's chest pain? (Amlodipine, Aspirin, Dihydroegrotamine, Morphine, Nitroglycerin, Phentolamine)
> This patient with spontaneous episodes of
rest and nighttime angina
transient ST elevation
on ambulatory ECG monitoring, likely has vasospastic or
variant (Prinzmetal) angina
. Variant angina is caused by transient, sudden, and significant reduction in the luminal diameter of an epicardial coronary artery due to spasm, leading to brief myocardial ischemia.
can occur in normal coronary vessels and at the site of atherosclerotic plaques
is an ergot alkaloid commonly used to treat acute migraine headache. This drug may induce vasospastic angina as it constricts vascular smooth muscle via stimulation of both alpha-adrenergic (partial agonist) and serotonerigic receptors. Other possible triggers include cigarette smoking, cocaine/amphetamines, and triptans.
> Phentolamine is nonselective alpha blocker and acts as a vasodilator. Although reflex tachycardia is known side effect of nonselective alpha blockers, studies have shown that vasospastic anger does not occur with phentolamine due to the underlying mechanisms of anger being coronary vasospasm and not coronary artery disease.
uWORLD: A 56 yo man with a history of hypertension and hyperlipidemia is brought to the ED with chest pain, diaphoresis, and lightheadedness. His symptoms started an hour ago while he was stacking boxes in his garage. He describes the pain as a tight squeezing sensation in the center of his chest that radiates down his left arm. Electrocardiogram shows ST-segment elevation in leads II, III< and aVF. The tissues affected by this patient's acute condition will most likely develop which of the following histologic changes over the next few days?
> Lethal tissue ischemia causes
in most tissues, including myocardium.
The exception is ischemic cell death in the central nervous system, which causes liquefactive necrosis.
uWORLD: A 50 yo man has recurrent episodes of paroxysmal A-Fib accompanied by uncomfortable palpitations and chest pressure. Echocardiogram revels normal biventricular function and no significant valvular disease. Coronary angiography reveals no obstructive coronary artery disease. The patient is started on medication to reduce his symptoms. Two weeks later, he is seen in the ED for lightheadedness, weakness, and pre syncope.ECG reveals sinus bradycardia at a rate of 53/min with QTc prolongation. Telemetry monitoring reveals a short episode of self-resolved roses de points. Which of the following medications was most likely used to treat his patient's palpitations? (Dilitazem, metoprolol, mexiletine, ranolazine, sotalol)
Sotalol has both beta adrenergic-blocking and class III antiarrhymic (K+ channel-blocking( properties and is occasionally used in treatment of atrial fibrillation. Major side effects of stall include bradycardia, pro arrhythmia, and most commonly tornadoes de points due to QT interval prolongation.
> Meotrpolol is a class II antiarrhymic drug that is a selective beta-1 receptor antagonist. It acts as a negative inotropic and chonrotropic agent by decreasing myocardial contractility and heart rate. Unlike stall, beta blockers do not have any potassium channel blocking properties and do not prolong the QT interval.
uWORLD: A 45 yo man comes to the hospital with acute onset of severe chest pain and diaphoresis. The patient describes the pain as "squeezing," different from any discomfort he has ever had. He has a past medical history of HTN, and his father underwent coronary artery bypass grafting at age 50. The patient is diagnosed with acute ST-elevation MI and undergoes an urgent coronary intervention with stent placement into the right coronary artery. He is also started on high-intensity atorvastatin therapy, along with anti platelet therapy, and appropriate medications to control blood pressure. Four weeks later, the patient's total cholesterol level is 140 mg/dL, down from 200 mg/dL before discharge. Which of he following has most likely increased as the result of the therapy?
LDL receptor density
> Treatment with statins causes hepatocytes to increase their LDL receptor entity, leading to increased uptake of circulating LDL.
is an apoprotein present in VLDL and LDL. Decrease in circulating LDL and VLDL will cause the ApoB-100 concentration to decrease as well
uWORLD: A 76 yo man is brought to the ED with severe midsternal chest pain and diaphoresis. Past medical history is significant for HTN, Type 2 DM, and asymptomatic right carotid artery stenosis. His blood pressure is 120/70 mmHg and pulse is 75/min. Lungs are clear to auscultation. ECG shows ST segment elevations greater than 1 mm in leads II, III, and aVF. The patient receives aspirin immediately upon arrival followed by alteplase and low-dose beta blocker. A single dose of intravenous morphine is given to for pain control. Several hours later, the patient is found to be comatose with asymmetric pupils and an irregular breathing pattern. What is the most likely cause of this patient's current condition?
> This patient's presentation of chest pain and diaphoresis along with a history of systemic atherosrerlosis and type 2 diabetes mellitus is suggestive of acute coronary syndrome. ECG findings are consistent with an inferior ST elevation
(STEMI). Percutaneous coronary intervention (PCI) or fibrolysis to achieve myocardial perfusion is recommended for acute MI patients who present within 12 hours of symptoms onset.
PCI is preferred
over fibrolytic therapy, due to lower rates of intracerebral hemorrhage (ICH) and recurrent MI; hover, it may not be available at all institutions. In such cases treatment twist firolytics (tenecteplase, alteplase) improves clinical outcomes in the absence of contraindications (eg, gastrointestinal bleeding, recent surgery)
> Fibrinolytic therapy for acute ST segment elevation myocardial infarction is a reasonable reperfusion technique for patients with no contraindications to thrombolysis. Fibrolytic agents such as
bind to fibrin in the thrombus (clot) and activate plasmin, which leads to thrombolyis.
The most common adverse effect of thrombolysis is hemorrhage (eg. gastrointestinal, intracerebral)
___________________ typically presents with severe, tearing chest pain that radiates to the inter scapular area. it occurs most commonly with hypertension and Marfan/Ehler-Danlos syndrome. Chest X-ray typically reveals a widened mediastinum.
_____________________ typically presents with small, constricted pupils (miosis) and respiratory depression (respirations usually <12/min)
______________________ presents with acute onset of dyspnea, pleuritic reset pain, and possibly hemoptysis. Tachycardia, hypotension, cyanosis, and loss of consciousness can occur when PE is severe.
Pulmonary embolism (PE)
_______________________ results in a left-to right shunt and symptoms of acute heart failure. It presents with chest pain, dyspnea, syptmosm of cariogenic shock, and a harsh holoystolic mummer on the left sternal border
Inter ventricular septum perforation
uWORLD: A 56 yo woman comes to the ED with facial swelling and difficulty breathing. She woke up today with a "feeling of fullness" in her lips, and 2 hours later her husband said that her lip looked puffy. There is no itching or skin rash. The patient has had no simmer symptoms before. She has a history of gastroesophageal reflux disses and take lansoprazole daily. Shells began taking lisinorpil 2 months ago for hypertension. The patient's blood press red 135/75 mmHg. On examination, there is moderate swelling of her lips and tongue. Milk audible stridor without wheezing is present. Which of the following the most likely mechanism responsible for this patient' symptoms?
is a rare serious adverse effect of ACE inhibitor therapy. ACE inhibition increases bradykinin levels, which increase vascular permeability and lead to angioedmea. Symptoms include tongue, lips, or eyelid swelling and, less frequently, laryngeal edema and difficulty breathing. ACE inhibitors should be discontinued in affected patients.
> ACE inhibitor-induced angiedmia is due to bradykinin accumulation. Normally ACE is responsible for bradykinin breakdown. ACE inhibitors prevent bradykinin degradation, leading to increased levels. Bradykinin is a potent
that ultimately increase
, causing significant angioedema. ACE inhibitors should be
in patients who develop angioedema.
uWORLD: A 82 yo man is brought to the ED with fatigue and palpitations. The patient was playing chess at the park when his symptoms developed suddenly. He immediately called an ambulance as he has never experienced symptoms like this before. Past medical history is significant for asthma, gout, hypertension. Blood pressure is 110/70 mmHg, pulse is 130/min, and rhythm is irregular irregular. The lungs are clear on auscultation. IV digoxin is administered. Two hours later, the patient appears comfortable; his pulse is 82/,in and still irregular irregular. Which of the following best explains the heart rate lowering effects of the medication?
Increase parasympathetic tone
> > This patient developed
atrial fibrillation with rapid ventricular response (AF with RVR)
and was treated with digoxin for ventricular
. Although calcium channel blockers and beta blockers are pereferd for rate control, digoxin, is sometimes used.
slows the ventricular rate during AF primary by
inreasing parasympathetic tone
, which leads to inhibition of AV nodal conduction
Delayed after-depoarlziaitons are abnormal depolarizatons of cardiac myoctyes that occur after repolarizaiton has completed. They can occur in states of hyperexcitiablty (eg. very high intracellular calcium, high catecholamine stimulation state). _____________ toxicity can cause delayed after-depaorlziaitons via its mechanism of increasing intracellular calcium, leading to ventricular tachycardia and death.
uWORLD: A 47 yo man with known CAD comes to the ED with chest tightness, wetting, and palpations. His symptoms began abruptly 2 hours ago while he was at work. Six months ago, the patient underwent percutaneous angioplasty of the right coronary artery. Past medical history also includes anxiety and panic attacks. Blood pressure is 180.90 mHg and pulse is 110/min with regular rhythm. An esmolol infusion produces rapid symptom relief and heart rate slowing. Which of the following portions of the ECG will be affected most significantly by the medication?
>Bea blockers decrease AV nodal conduction, leading to an increase AV nodal refractory period. This correlates to PR interval prolongation on an ECG.
uWORLD: A 53 yo man comes to the ED due to 2 weeks of intermittent low-grade fevers and fatigue. Temp is 38.5 C, blood pressure is 120/80, pulse is 92/min, and respirations are 16/min. On cardiovascular examination, an early diastolic murmur is present and best heard at the left sternal edge. Sublingual splinter hemorrhages are seen. Laboratory study results show leukocytosis and an elevated erythrocyte sedimentation rate. Blood cultures are drawn and grown gram-positive cocci that synthesizes dextran from sucrose. The organism contributing to this patient's current condition is also associated with which of the following?
(Anterior uveitis, colon cancer, dental caries, erythema nodosum, glomerulonephritis, migratory polyarthritis)
produce dextrans that aid them in colonizing host surfaces, such as dental enamel and heart valves. These organisms cause subacute bacterial endocarditis, classically in patients with preexisting cardiac vavluar defects after dental manipulation.
_____________________ is associated with colon cancer, and patients with this type of of bacterial endocarditis should undergo colonoscopic evaluation to exclude neoplasia.
Erythema nodosium (erythematous to violaceous subcutaneous nodules usually appearing on the legs) is a nonspecific finding. It is associated with multiple bacterial infections, most commonly ___________________. It is also associated with Crohn disease, sarcoidosis, and other inflammatory conditions.
S pyogenese pharyngitis, but also Staphylococcus aureus, fungi (eg. Coccidioidomycosis, histoplasmosis, blastomycosis), chlamydia, and other
Migratory polyarthritis is a characteristic of rheumatic fever, an immune-mediated disease. These conditions typically follow infection with ________________________, which does not produce dextrans
Group A Streptococcus (S pyogenes)
uWORLD: A 15 yo male suffers severe cardiomyopathy following an infective myocarditis from Coxsackle virus and is placed on the cardiac transplant list. Two weeks following his cardiac transplantation from a matched donor, he is suffering dyspnea on exertion. Extensive evaluation is undertaken in this patient including cardiac catheterization and endomyocardial biopsy. Which of the following findings is most consistent with acute graft rejection?
Dense interstitial lymphocytic infiltrate
> Acute cardiac transplant rejection occurs weeks following transplantation and is primarily a cell-mediated process. On histopatholgic analysis of an endomyocardial biopsy, a dense mononuclear lymphocytic infiltrate with cardiac myocyte damage will be visualized. Treatment with immunosuppressive drugs is aimed primarily at preventing this form of rejection.
Patchy necrosis with granulation tissue
is indicative of ______________ damage to the donor heart.
> Ischemia in a donor heart can occur in a variety of situations including ischemia during attempted resuscitation of the donor patient, during transport of the organ from the donor to the recipient, and acutely during initial perfusion of the organ after transplantation. Ischemia can also occur simply due to atherosclerosis in the donor heart causing classic myocardial ischemia.
uWORLD: A 65 yo man comes to the office due to exertion dyspnea and easy fatiguability. He has no the medical problems. The patient has not seen a physician in the last 10 years. He takes no medications but smokes a pack of cigarettes per day and drinks approximately 7-10 alcoholic beverages a week. His blood pressures is 170/90 mmHg and pulse is 80/min. Physical examination reveals bilateral lung crackles. Which of the following sets of diagnostic findings would be most consistent with isolated diastolic heart failure? (Increase/decrease/normal: Left ventricular end-diastolic pressure, Left ventricular end-diastolic volume, Left ventricular ejection fraction)
> Left ventricular end-diastolic pressure: Increase
> Left ventricular end-diastolic volume: Normal
> Left ventricular ejection fraction: Normal
Diastolic heart failure is caused by decreased ventricular complacent and is characterized by normal left ventricular (LV) ejection fraction, normal LV end-diastolic volume, and elevated LV filling pressures.
A 65 yo Caucasian male presents to the ER with sudden onset of right-sided calf and foot pain. His past medical history is significant for HTN, Type II DM, atrial fibrillation and stable angina. Physical examination reveals paleness of the right leg and diminished right popliteal pulse. Immediate angiography is ordered that reveals an obstructive thrombus in the right common femoral artery. The thrombus extracted is followed by a rapid surge of serum creatine kinase level, which is best explained by:
Cell membrane damage
>When the cells within heart, brain, or skeletal muscles are injured, the enzyme creatine kinase leaks across the damaged cell membrane and into circulation (as seen in this patient).
> Repercussion injury is though to occur secondary to oxygen free radical generation, mitochondrial damage, and inflammation.
A 2 month old boy is found unresponsive in his crib. He had previously been well and had a normal physical examination at his 2 month visit approximately 1 week early. An autospy is performed to determine the cause of death. The pathologist concludes that the infant likely died of sudden infant death syndrome. The autospy also shows an incidental finding of bicuspid aortic valve. If this patient had survived, he would have been at greatest risk for which of the following?
Aortic stenosis in his 50s
> Aortic stenosis is the most common complication of bicuspid aortic valves. Patients with bicuspid aorta calves develop clinically significant aortic stenosis on average around age 50. In comparison, senile calcify stenos of normal aortic valves generally becomes symptomatic age > 65.
> Bicuspid aortic valves (right and left aortic cusp fusion) occur in approximately 1%-2% of live births, making it one of the
congenital heart defects.
_______________ tends to increase left atrial pressure during diastole (not systole) due to a pimrary obstruction of left ventricular filling
A left heart catheterization shows an excessive rise in left atrial systolic pressure, a finding that is characteristic for __________________________
________________ deficiency is an autosomal recessive disorder that does not typically cause clinically significant bleeding despite aPPT prolongation.
Hageman factor (factor XII)
uWORLD: A 68 yo man comes to the office with a 6 week history of muscle pain and fatigue. He has achy pain that is not related to activity. The patient has tried warm compresses and over-the-counter analgesics without relief. Past medical history is significant for HTN, mixed hyperlipidemia, and coronary artery disease with an acute myocardial infarction 2 years ago. Physical examination shows diffuse tenderness in the proximal muscles of the upper and lower extremities. Serum creatine kinase activity is elevated. Which drug combination is most likely for this patient
Atorvastatin and gemfibrozil
> The primary side effects of statins include myopathy and hepatitis.
is usually characertized by mild muscular pain and resolves with discontinuation of the medication. However, some patents will develop severe myopathy with striking elevations in creatine kinase levels and occasional rhabdomyolysis.
> The risk of severe myopathy is increased with statins are given concurrently with fibrates (particularly
), which impair the hepatic clearance of statins and lead to excessive blood levels. An increased risk of statin myopathy is also likely with concurrent use of niacin or ezetimbe, but to a lesser extent.
uWORLD; A 46 yo man with 30-pack-year smoking history develops right leg pain and swelling after returning from an overseas trip. He is diagnosed with a lower extremity deep venous thrombosis and is started on intravenous heparin. Shortly after being hospitalized, he develops right-sided weakness and facial droop. CT scan of the head reveals a left middle cerebral artery stroke. Which of he following physical examination findings is most likely to be present in this patient?
Wide splitting of S2 that does not change with respiration
> Paradoxical embolism occurs when a thrombus from the venous system crosses into the arterial circulation via an abnormal connection between the right and left cardiac chambers (eg, patent foramen ovale, atrial septal defect, or ventricular septal defect). Atrial left-to-right shunts cause wide and fixed splitting of S2 and can facilitate paradoxical embolism due to periods of transient shunt several (eg, during straining or coughing) .
A cerebrovascular event
(eg transient ischemic attack, stroke) in the setting of known venous thromboembolic disease is suspicious for
. Paradoxical emboli originate in the systemic venous circulation (lower or upper extremities) and enter the systemic arterial circulation via an intracardiac or intrapulmonary shunt. They can occur in patients with
patent foramen ovale, atrial septal defect,
ventricular septal defects, or large pulmonary arteriovenous malformations.
> Atrial septal defects with left-to-right shunt typically cause
wide and fixed splitting
(no change with respiration) of the second heart sound (S2).
uWORLD: A 37 yo man is brought to ED following a motor vehicle accident in which he was the unrestrained driver. Paramedics report that his breath smelled of alcohol at the scene. En course to the hospital, the patient receives 2 L intravenous normal saline. In the ED, his blood pressure is 100/60 mmHg, pulse is 130/min, and respiration are 44/,in. He is admitted directly to the intensive care unit, where he is intubated and placed on mechanical ventilation. A decision is made to insert a central venous catheter. In addition to sterile draping during the procedure, which of the following actions would be most likely to prevent intravascular catheter-related infections?
Alcohol-based hand scrub prior to beginning the procedure
> Central venous catheters (CVCs) are commonly used for hemodynamic monitoring and administration of fluids and medications in critically ill patients.
, primary coagulase-negative staphylococci and Staphylococcus aureus, account for the majority of these infections.
> Topical antimicrobial ointments do not reduce the rate of CVC-related infections and are associated with increased risk of antimicrobial resistance and Candida colonizations
________________ is characterized by a continuous murmur heard best in the
left intraclavicular region
with maximal intensity at S2. It occurs most commonly in patients born prematurely and those with cyanotic congenital heart disease.
Patent ductus arteriosus (PDA)
uWORLD: A 34 yo woman comes to the office due to progressive exertion dyspnea for the past 6 months. She has no chest pain, lightheadedness, or syncope. Past medical history is unremarkable and the patient take no medication. She does not use tobacco, alcohol, or illicit drugs. The patient's mother died of pulmonary arterial hypertension at age 32. Blood pressure is 125/72 mmHg and pulse is 75/min. BMI is 23 kg/m2. Examination reveals clear breath sounds without wheezes or crackles and a loud second heart sound at the left upper sternal border. Chest x-ray reveals clear lung fields. ECG shows right axis deviation. If this patient's condition is inherited, which of following is the most likely cause of her disease.
Vascular smooth muscle proliferation
> Pulmonary arterial HTN follows a 2-hit hypothesis. An abnormal BMPR2 gene acts as the first insult and predisposes to excessive endothelial and smooth muscle cell proliferation. A second insult is then though to activate the disease process, resulting in vascular remodeling, elevated pulmonary vascular resistance, and progressive pulmonary hypertension.
uWORLD: A 60 yo man who was recently diagnosed with HTN comes to there office for follow-up. he was treated with lisinopril but stopped a week ago due to dry, nagging cough. Past medical history is notable for type 2 diabetes mellitus with moderately increased albuminuria but normal creatinine clearance. His other medications include metformin and rosuvastatin. The patient does not smoke or drink alcohol. His blood pressure is 150/92 mmHg. BMI is 31 kg/m2. Physical examination, including the heart and lungs, is unremarkable. Which of the following is the best treatment for this patient's hypertension? (Diltiazem, hydrazine, metoprolol, ramipril, valsartan)
Angiotensin-coverting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) reduce the risk of chronic kidney disease in patents with hypertension and diabetes. ACE inhibitors raise levels of bradykinin and can cause a nonproductive cough, an effect not seen in ARBs.
> Angiotensin receptor blockers (ARBs) have hemodynamic effects similar to those of ACE inhibitors but do not affect bradykinin levels and do not cause a cough. Replacing this patient's ACE inhibitor with and ARB (eg. losartan, valsartan) will eliminate the cough while still providing the same long-term renovascular benefits.
> Careful blood pressure control can help reduce the long-term risk of kidney injury, regardless of the agent used. However, none of these drugs are as effective as ACE inhibitor with an ARB for preventing the progression of chronic kidney disease.
uWORLD: A 22 yo Caucasian male presents to the ED complaining of severe headache and vomiting. Soon after, he slips into a coma and dies. Autospy shows a ruptured cerebral aneurysm with extensive intracranial hemorrhage. This patient's condition is most likely associated with:
Coarctation of the aorta
> Patients with adult-type coarctation of the aorta commonly die of hypertension-asscoaited complications, including left ventricular failure, ruptured dissecting aortic aneurysm, and intracranial hemorrhage. These patients are at increased risk for ruptured intracranial aneurysm because of the increased incidence of congenital berry aneurysms of the Circle of Willis as well arch hypertension.
> Isolated atrial or ventricular septal defects are not commonly associated with spontaneous rupture of intracranial aneurysms in young adults. HOWEVER, the incidence of thromboembolic stroke as the result of paradoxical embolism might be increased in patients with an atrial or ventricular septal defect and LATE-ONSET right-to-left shunting.
uWORLD: A 64 yo woman comes to the ED with substernal chest pain that started 6 hours ago. Past medical history includes HTN and Type 2 DM. ECG shows sinus rhythm with ST segment elevations in leads V1 to V5. She receives intravenous fibrinolytic therapy. The pain persists for 6 hours after admission, requiring intravenous morphine therapy. Despite adequate resuscitative therapy, the patient dies suddenly several days later while hospitalized. Autospy finds a slit-like tear. Which of the following satinets best describes the condition that caused this patent's death?
It typically occurs within 5-14 days after an acute myocardial infarction
> Left ventricular free wall rupture usually occurs within 5-14 days after an initial myocardial infarction and presents with sudden onset of chest pain, profound shock, and rapid progression to death. Morphologically, rupture appear as a
in the infarcted myocardium, with a preference for the left ventricle due to high systolic pressures.
uWORLD: A 22 yo woman comes to the physician complaining of worsening dyspnea. She has also experienced low-grade fevered, a 15 pound weight loss, and syncopal episodes over the last 3 months. Her SOB worsens when sitting and improves when lying down. Her past medical history is insignificant. She does not smoke, drink alcohol, or use illicit drugs. her temperature is 37.4 C, pulse is 75/min and regular, blood pressure is 115/72, and respirations are 12/min. Her lungs are clear. Cardiac auscultation reveals a low-pitched, mid-diastolic rumble at the cardiac apex. The remainder of her physical examination is normal. ECG rivals left atrial enlargement, and echocardiography shows a large pedunculate mass attached to the left atrium. Histologic analysis of this mass will most likely reveal which of the following?
Scattered cells within a mucopolysaccharide stroma
> The combination of constitutional symptoms, a mid-diastolic rumbling murmur heard best at the apex, positional dyspnea, and a large pedunculate mass in the left atrium is highly suggestive of an atrial myxoma.
are the most common primary cardiac neoplasm and approximately 80% arise in the left atrium.
> Constitutional symtoms, a mid-diastolic rumbling mummer heard best at the apex, postieornal cardiovascular symptoms (eg. dyspnea and syncope), embolic symptoms, and large pedunculate mass in the left atrium are the typical finding of atrial myxoma. Histologically, these tumors are composed of scattered cells within a mucopolysaccharide stroma, abnormal blood vessels, and hemorrhaging.
uWORLD: A 23 yo woman comes to the hospital due to fever, chills, dyspnea, and cough for the past several days. She also has sharp right-sided chest pain exacerbated by breathing. Her temperature is 39 C (102 F), blood pressure 115/70 mmHg, and pulse is 108/min. On examination, the patient has several needle track marks on both arms. There is a 3/6 holosytolic mummer heard beset at the lower sternal border that increases on inspiration. Chest imagine reveals scattered bilateral peripheral lungs opacities. HIV testing is negative. This patient's blood cultures are most likely to grow which of the following organism?
> Staphylococcus aureus causes acute bacterial endocarditis with rapid onset of symptoms, including shaking chills (rigors), high fever, dyspnea on exertion, and malaise. In intravenous drug users, it can cause right-sided endocarditis with septic embolization into the lungs.
uWORLD: A 34 yr old immigrant from South Asia presents to your office complaining of heart palpitations that are particularly prominent at night. He also notes that with moderate exertion, he experiences head "pounding" accompanied by involuntary head bobbing. He remembers being diagnosed with a heart murmur years before, but he cannot recall the type and has never received any treatment. Based on this patient's history, you suspect:
Widening of the pulse pressure
> The abnormally large (wide) pulse pressure caused by aortic regurgitation (AR) is responsible for many of the symptoms and signs of AR.
> The patient complains of nocturnal palpitations and head pounding with exertion. Palpitations may result from forceful ventricular contractions ejecting large stroke volumes, and head pounding can be due to usually high amplitude pulsations of the intracranial arteries with each heartbeat. Involuntary head bobbing can be sign of widened pulse pressure.
uWORLD: A 42 yo woman comes to the ED for evaluation of chest pain. She was moving furniture in her summer house 2 days ago when she experienced sharp pain in the left side of the sternum that quickly subsided. Since then, the patient has had episodic pain with deep inspiration or trunk movement. She has no fever or cough. The patient has a history of HTN. Her father died of MI at age 67. She does not use tobacco or illicit drugs. Blood pressure is 146/85 mmHg in the right arm and 142/80 mmHg in the left arm, pulse is 86/min, and respirations are 12/min. She has localized tenderness to palpation at the left sternal border. Lungs are clear to auscultation, and cardiac examination reveals normal heart sounds without gallops or murmurs. The abdomen is soft and contender. There is no peripheral edema. Which of the following is the most likely cause of this patient's symptoms?
> Costosternal syndrome (costochondritis) usually occurs after repetitive activity and is characterized by pain that is
reproducible with palpation
and worsened with movement or change in position.
- Aortic (direction, intramural hematoma)
- Chest wall/musculosketetal
uWORLD: A 66 yo man comes to the office for a routine visit. He has a history of hypertension and osteoarthritis. The patient has smoked a pack of cigarettes daily for 40 years and occasionally drinks 1 or 2 glasses of wine but does not use illicit drugs. Blood pressure is 142/82 mmHg and pulse is 80/min. Cardiopulmonary examination is normal. There is a pulsating, central abdominal mass on physical examination. Which of the following pathologic conditions is the most likely underlying cause of this patient's abnormal findings?
Chronic transmural inflammation
> Abdominal aortic aneurysm is associated with risk factors (eg, age >60, smoking, HTN, male sex, family history) that lead to chronic transmural inflammation and extracellular matrix degradation within the wall of the aorta. This leads to weakening and progressive expansion of the aortic wall, resulting in aneurysm formation, typically below the renal arteries.
___________________ is characterized by loss of smooth muscle, collagen, and elastic tissue with formation of cystic mucoid spaces in the aortic media. Patients with Marfan syndrome develop cystic medial degeneration of the aortic root at a young age, predisposing them to ascending aortic aneurysm and dissection.
Cystic medial necrosis
Malignant endothelial prolifération is characteristic of _____________________, a neoplasm that arises from blood or lymphatic vessels in the subcutaneous tissue and most frequently affects the scalp and face.
An _____________ in the aortic wall is the primary event involved in the pathophysiology of aortic dissection. Patients typically present with tearing chest pain that radiates to the back. Proximal dissections involving the ascending aorta can cause unequal blood pressure in the arms, aortic valve regurgitation (eg. diastolic decrescendo mummer at the right sternal border), and cardiac tamponade.
A 54 yo man comes to the office due to 2 day son redness and pain in his right arm. he was recently diagnosed with superficial thrombophlebitis involving the left lower and upper extremities. His symptoms then subsided within days of NSAID therapy only. The patient has no other past medical history. He has some abdominal discomfort that he attributes to gastroesophageal reflux disease. Temperature is 99.7 F. On examination, there is erythema and tenderness extending linearly from the right forearm to just anterior to the right antecubital fossa. No fluid collection is palpable. Complete blood count shows mild leukocytosis. The patient's symptoms may indicate the presence of which of the following?
should raise suspicion for
. Hyper coagulability is very common paraneoplastic syndrome seen most frequently in
adenocarcinomas of the
, colon, and lung.
develops because adenocarcinomas produce a thromboplastin-like substance capable of causing chronic intravascular coagulations that can disseminate and tend to migrate
> Migratory superficial thrombophlebitis, known as
> Trousseau also described the Trousseau sign (hand/forearm muscle spasms on sphygomanometric measurement)
Celtic sprue has been associated with a _____________________ (Rather than abnormal thrombosis). The malabsorption resulting from celiac sprue can result in vitamin K deficiency.
hemorrhagic diathesis (rather than abnormal thrombosis)
uWORLD: A 34 yo male diagnosed with acute myelogenous leukemia recently underwent successful induction chemotherapy with doxorubicin. Several weeks later, he presents to your office complaining of progressive exertion dyspnea and orthopnea. Which of the following is most likely responsible for this patient's symptoms?
> The anthraycline chemotherapeutic agents (doxorubicin, daunorubimcin, epirubicin and idarubicin) form free radicals in the myocardium. Their most severe side effect is a cumulative dose-related dilated cardiomyopathy. It presents with symptoms of left and right ventricular CHF.
A 1 week old boy is brought to the office for his first primary visit following an uncomplicated vaginal delivery at 40 weeks gestation. The boy was born to a 30 yo woman who took prenatal vitamins throughout the pregnancy. She was diagnosed with gestational diabetes mellitus at 28 weeks gestation, which was treated with dietary modification and exercise. The nursery course was uncomplicated, and the boy wad discharged at around 30 hours of life following observation of appropriate breastfeeding, voiding, and stopping. His weight, length, and head circumference are at the 50th percentile. Physical examination shows a grade II/VI harsh, holosystolic mummer best heard at the left mid to lower sternal border. Birth records show that no murmur was heard by 2 different health care providers in the newborn nursery. Which of the following is the most likely diagnosis?
> Ventricular septal defect (VSD) typically presents in the neonatal period
after pulmonary vascular resistance has declined
. The clinical presentation depends on the size of the defect, which ranges form an asymptomatic holosystolic murmur (small VSD) to heart failure (large VSD)
uWORLD: A 55 yo Caucasian male is brought to the ER with sudden onset severe substeranl chest pain, as well as sweating and mild dyspnea. The pain does not respond to aspirin or sublingual nitroglycerin. His past medical history is significant for HTN, diabetes and hyperlipideam ECG demonstrates ST-segment elevation in leads I, aVL and V1-V3 with deep Q-wave development over the several hours. Cardiac catherizaiton in this patient would most likely show which of the following
Ruptured atherosclerotic plaque with fully obstructive thrombus
> An acute transmural MI marked by ST-elevation and subsequent Q-wave formation is most likely the result of a fully obstructive thrombus superimposed on a ruptured atherosclerotic coronary artery plaque. A lesser degree of occlusion by a thrombus superimposed on an acute plaque change would more likely cause unstable angina. A stable atheromatous lesion without a overlying thrombus, but obstructing greater than 75% of the coronary artery lumen, would likely cause only stable angina.
NOT Prinzmetal's angia
> The vasospasm of Prinzmetal's angina generally responds promptly to vasodilators, such as nitroglycerin.
uWORLD: Autospy of a 78 yo man demonstrates decreased left ventricular cavity size and a sigmoid-shaped ventricular septum. Light microscopy shows increased collagen content within the ventricular wall. Some myocardial cells also have brownish perinuclear cytoplasmic inclusions. The changes described are most consistent with which of the following conditions?
> Normal morphological changes in the aging heart include a
decrease in left ventricular chamber apex-tobase dimension
, development of a sigmoid-shaped ventricular septum, myocardial atrophy with increased collage deposition, and accumulation of cytoplasmic lipofuscin pigment within cardiomyocytes.
__________________ may result in the formation of hemosiderin granules containing excess iron inside cardiac myocytes (hemosiderosis), which can be visualized with Prussian-blue stain. Excessive deposition of iron within the myocytes usually leads to dilated or restrictive cardiomyopathy
Chronic hemolytic anemia
Extreme myofibril disarray with interstitial fibrosis on cardiac histology strongly suggests _______________________.
Hypertrophic cardiomyopathy (HCM)
> Almost 100% cases of HCM results from mutations in gene encoding cardiac sarcomas protein (most commonly beta-myosin heavy chain).
uWORLD: A 50 yo man is brought to the ER with severe dizziness and confusion. he states that he had an episode of chest pain and took several tablets of nitroglycerin. His current medications include a daily aspirin for heart attack prevention, an occasional acetaminophen for headaches and occasionally tadalafil for erectile dysfunction. His blood pressure is 50/20 mmHg and his heart rate is 120 beats/min. Which of the following cellular changes is most likely responsible for this patient's symptoms?
Cyclic GMP accumulation
> Using nitrates together with phosphodiesterase (PDE) inhibitors used for erectile dysfunction and pulmonary hypertension causes a profound systemic hypertension because they both increase intracellular cGMP which causes vascular smooth muscle relaxation. Their use together is absolutely contraindicated.
uWORLD: A 49 yo woman is brought to the ED with squeezing chest pain and profuse sweating for the last 2 hour. Past medical history includes diet-controlled type 2 diabetes mellitus. ECG reveals ST-segment elevation in leads I, aVL, and V1-V4. The patient is immediately taken to the cardiac cauterization laboratory where she is found to have complete occlusion of the left anterior descending coronary artery. The blockage is immediately opened, but after the intervention, she experiences recurrent and sustained episodes of ventricular arrhythmia. She is treated with antiarrhytmic agents. One of the agents used in this patient preferentially binds to rapidly depolarizing and ischemic ventricular myocardial fibers and has minimal effect on normal ventricular myocardium. Which of the following agents was most likely used in this patient?
(Adenosine, digoxin, diltiazem, ibutilide, lidocaine, metoprolol, procainamide)
> The patient sustained an anterolateral ST elevations myocardial infarction (MI) with successful repercussion with percutaneous coronary intervention.
(ventricular premature beats, ventricular tachycardia, ventricular fibrillation) are quite common in the first 24-48 hours after MI. Premature beats or nonsustatined arrhymias do not require any specific therapy, whereas recurrent,
arrhythmias are often managed with anti arrhythmic drugs. Intravenous
is generally considered the drug of choice in such as setting, with intravenous
as a second-line agreement when amiodarone is not readily available or effective in suppressing the arrhythmia.
. > Class IB drugs like lidocaine are the weakest sodium channel blocker (dissociate the fastest) and have a negligible effect on QRS duration in normal cardiac tissues. The agents predmoniatly bind to sodium channels in the inactivated state.
> Ischemic myocardium has higher than normal resting membrane potential, which delays voltage-dependent recovery of sodium channels from the inactivated to the resting state.
> This allows increased binding of class IB agents; therefore, class IB antiarrhytmics are highly efficacious in inhabiting ischemia-induced ventricular arrhythmias.
___________________ causes transient conduction delay through the atrioventricular node and is used in the acute treatment of
paroxysmal supraventrciular tachycardia
; it is NOT indicated in ventricular arrhythmias
____________ enhances vagal tone and leads to an increased effective refractory period and decreased conduction velocity through the AV node. These actions are useful in amassment of patients with
Pulmonary embolism is common in hospitalized patients. Large emboli lodge in the pulmonary artery bifurcation. Smaller emboli occlude the peripheral branches of the pulmonary artery, producing wedge-shaped, red "hemorrhagic" infarcts. This condition is precipitated by hyper coagulability and can be prevented by the anticoagulant ____________
Aspirin blocks thromboxane A2 synthesis and prevents platelet aggregation. Low-dose aspirin plays an important role in the presentation of recurrent coronary artery thrombosis and ischemic strokes. Aspirin alone is not enough to prevent DVT/PE in high-risk patients (eg. those undergoing hip surgery).
_________ is a class II antiarrhthmic drug (potassium channel blocker) and is occasionally used for acute termination of atrial flutter and fibrillation. It prolongs QT interval and increases the risk of polymorphic ventricular tachycardia (tornadoes de points)
uWORLD: A 59 yo African American male presents to the ED with crushing chest pain, sweating, and lightheadedness. His blood pressure is 90/60 mmHg and his heart rate is 48 bpm. ECG shows sinus bradycardia and ST segment elevation in leads II, III, and aVF. Occlusion of which coronary artery is most likely responsible for the patient's symptoms?
right coronary artery
> In 90% of individuals, occlusion of the
right coronary artery
can result in transmural ischemia of the inferior wall of the left ventricle, producing ST elevation in leads II, III, and aVF as well as possible sinus node dysfunction.
> Occlusion of the
would be expected to result in anteroseptal transmural ischemia, with ST selections in leads V1-V2
> Occlusion of the
would produce transmural ischemia of the lateral wall of the left ventricle, with ST elevations mainly in V5 and V6, and possibly also in I and aVL.
uWORLD: A 60 yo man with known coronary artery disease comes to the office due to exertion chest tightness for the last 6 months. The symptoms occur when he walks more than 3 blocks, especially in cold weather. The patient underwent coronary artery bypass graft surgery 3 years ago for progressive angina. Past medical history also includes asthma, benign prostate hyperplasia, and peripheral artery disease. The physican discusses adding isosobride denigrate to this current therapy but the patient is concerned about adverse effects. Which of the following is most likely to occur in this patient with the add-on therapy?
> The main adverse effect seen with nitrate therapy include
headaches, cutaneous flushing,
, and reflex tachycardia. Nitrates must be avoided in patients with hypertrophic cardiomyopathy (due to increased outflow tract obstruction), right ventricular infarction (due to reduction in preload, impairing cardiac output), and those on phosphodiesterase inhibitors (synergism increases the risk of severe hypotension).
Nocturnal wheezing can be a symptom of asthma or gastroesophageal reflux disease. In addition, the use of ________________ in patients with underlying bronchospastic disease can cause increased bronchoconstriction and lead to wheezing.
________________ (medication) can lead to hyperuricema and precipitate an acute gout attack
________________ is a common side effect of opioid angalesics, iron supplements, calcium channel blockers such as verapamil, and anticholinergic medications such as atrophine
________________ due to Raynaud phenomenon are associated with medications such as amphetamines, ergotamine, and chemoterapetuic agent.s
uWORLD: A 65 yo man with Type 2 DM comes to the office due to decreased sexual performance over the last 6 months. The patient says his libido, muscle strength, and energy levels are normal, but his erections are inconsistent,w eat, and of inadequate duration for sexual activity. Past medical history is positive for hypertension, but he has no history of coronary artery disease and no suspicious chest pain. Bilateral ankle brachial index testing is within normal limits. The patient is treated with sildenafil, which give significant improvement in his sexual performance. The intracellular signaling of this drug is most similar to that of which of the following substances?
Brain natirjuertic peptide
> Atrial natriuretic peptide, brain natriuretic peptide, and nitric oxide activate guanylyl cyclase and increase conversion of guanosine 5'-triphosphate to cyclic guanosine 3',5'-monophophate (cGMP). Phosphodiesterase inhibitors (eg sildenafil) decrease the degradation of cGMP. Elevated intracellular cGMP levels lead to relaxation of vascular smooth muscle and vasodilation.
uWORLD: A 60 yo man comes to the ED with dizziness and palpitations. He is diagnosed with a cardiac arrhythmia and started on a mediation that is known to signicnatly prolong the QT interval on ECG. However, the drug is associated with a lower incidence of tornado de points than the other QT-prolonging agents. Which medication is most likely used?
> Amiodarone (and other class III and class Ia anti arrhythmic agents) cause lengthening of the cardiac action potential, which manifests as QT interval prolongation on ECG.
> In contract to other drugs, QT prolongation caused by amiodarone is associated with a very low risk of tornadoes de points and other proarrhythmias.
> This effect is thought to be due to it having a more homogenous effect on ventricular depolarization compared to other drugs (i.e., less QT dispersion)
uWORLD: A 53 yo man comes to the physician for a follow up visit after an acute MI. His medications include metoprolol and low-dose aspirin. He used to smoke 2 packs of cigarettes daily but quit after this myocardial infarction. The patient's father has hypertension and his mother has type 2 diabetes mellitus. He currently weighs 100 kg (220 lb) and is 178 cm (70 in) tall. Examination shows an obese male with no other abnormalities. His total serum cholesterol level is 155 mg/dL, with an HDL level of 27 mg/dL and a triglyceride level of 92 mg/dL. Which of the following lipid-lower agents would be most effective for preventing future cardiovascular events in this patient?
> Although low HDL concentrations is associated with increased Cardiovascular risk, the use of medication to raise HDL levels does not improve cardiovascular outcomes. HMG-CoA reductase inhiigor (statins) lower total cholesterol and LDL levels. Statins are the most effective lipid-loweringdurgs to primary and secondary prevention of cardiovascular events, regardless of baseline lipid levels.
Vibrates activate peroxisomal proliferator-activated receptor alpha, a transcription factor that increases lipoprotein lipase activity. Vibrates decrease triglyceride levels and raise HDL elves. However, fibrous are inferior to statins for reducing cardiovascular events and are primarily used to prevent _________________ in patients with very high triglyceride levels.
uWORLD: A 46 yo Caucasian male who presented with abdominal pain is diagnosed with a rare vascular tumor. This type of tumor is oftentimes associated with past arsenic or polyvinyl chloride exposure. Immunohistochemical staining of the tumor cells is positive for the CD31 cell marker. The patient most likely has which of the following conditions?
> Hepatic angiosacroma is associated with exposure to carcinogens such as arsenic, thorotrast, and polyvinyl chloride. Tumor cells express CD 31, and endothelial cell marker.
uWORLD: A 45 yo man comes to the ED with shortness of breath and fatigue that has been progressive over the the last 2 weeks. The patient was diagnosed with non-ischemic cardiomyopathy 2 years ago and has not been compliant with physician visits and his medical regimen. Blood pressure is 106/58 mmHg, and pulse is 88/min and regular. The patient looks uncomfortable when lying flat. Jugular venous pressure is elevated. Bibasilar crackles are heard on lung auscultation and a third hear sound is present. There is 1+ bilateral lower extremity pitting edema. Million infusion initiated as part of medical therapy. Which of the following responses is most likely to be seen in this patient?
> Phosphodiesterase-3 inhibitors such as milrinone and iamrinone lead to an increase in intracellular cyclic adenosine monophosphate (cAMP) concentration, which promote intracellular calcium influx and increase cardiac contractility. An increase in cAMP concentration in the vascular smooth muscle cells also causes systemic vasodilation, which limits the use of milrinone and inamrinone is several hypotensive patients.
uWORLD: A 22 yo woman comes to the ED due to intermittent fever and chills over the past few days. Last week, she underwent routine dental cleaning with no complications. The patient has a history of mitral valve prolapse. Temperature is 38.2 C (100.8 F). Physical examination revels a non-ejection mid-systolic click followed by a late-systolic murmur best heard at the cardiac apex. Blood cultures are drawn and grow gram-positive bacteria that synthesize dextran from sucrose. Which of the following would be the most likely adherence site for these bacteria.
> Viridans streptococci are normal inhabitants of the oral cavity and are a cause of transient bacteria after a dental procedures in healthy and diseased individuals. In patients with pre-existing valvular lesions, viridian's streptococci can adhere to fibrin-platelet aggregates and establish infection that leads to endocarditis.
uWORLD: A 66 yo man comes to the physician for a follow-up appointment. He is being treated for stable angina and long-standing hypertension. Physical examination is within normal limits. His serum laboratory results are as follows:
Sodium, chloride, bicarbonate, calcium, creatinine: normal;
Potassium: Slightly elevated.
Which drug in combination with lisinopril is most likely to account for this patient's laboratory abnormality?
ACE inhibitors block the conversion of angiotensin I to angiotensin II, thus reaching vasoconstriction and aldosterone secretion. Decreased aldosterone causes increased potassium retention, which can potentially lead to hyperkalemia.
> Hyperkalmea secondary to ACE inhibitors theory is most common in patients with renal insufficiency and in patients taking K+-sparing diuretics (amiloride, triamterene, and spironolactone) or K+ supplements.
> Indapamide an HCTZ are thiazide diuretics that work by blocking Na+-Cl- symporters in the distal tubules resulting in increase sodium and water excretion.
> Furosemide is a loop diuretic that works by blocking the Na+-K+-2CL- symporter in the ascending limb of the loop of Henle.
> All of these agents values hypokalemia. .
Endocardial thickening and noncompliant ventricular walls are suggestive of ____________________, which may be idiopathic or due to conditions scubas amyloidosis, sarcoidosis, or endomyocardial fibrosis.
Restrictive cardiomyopathy (RCM)
_______________ is associated with dilation of all chambers of enlarged, heavy, and flabby heart, with associated mural thrombus
Dilated cardiomyopathy (DCM)
uWORLD: A 62 yo man is hospitalized for chest pain and palpitations. His past medical history is significant for coronary artery disease, ischemic cardiomyopathy, paroxysmal atrial fibrillation, and hypertension. Blood pressure on admission is 135/78 mmHg and pulse is 78/min. During hospitalization, the patient has 2 episodes of brief loss of concsicouness. ECG recording during the episodes shows polymorphic QRS complexes that change in amplitude and cycle length. Between the episodes, his ECG shows QT interval prolongation but is otherwise unremarkable, Which medication is most likely responsible for this paint's condition?
(Digoxin, Dilimiazem, Lidocaine, Metoprolol, Sotalol)
QT prolongation may be acquired or congenital
Acquired AQ prolongation
is most frequently caused by electrolyte imbalances
hypokalemia, hypomagnesemia) and pharmacologic agents such as
class IA and III antiarrhythmics (eg. quinidine, stator), antibiotics (eg. macrocodes, fluoroquinolone), methadone, antipsychotics (eg. haloperidol). Sotalol is a class III anti arrhythmic agent (K+ channel blocking) used for treatment of atrial fibrillation. It prolong action potential duration, resulting in QT interval prolongation.
Digoxin slows conduction through the AV node by augmenting vagal parasympathetic tone, and it increases cardiac contractility by inhibiting the Na+/K+-ATPase (increasing intracellular calcium). It also decrease the action potential duration and can cause QT interval ______________.
uWORLD: A 64 yo woman comes to the hospital due to sudden-onset right arm weakness and difficulty speaking, which completely resolves within 20 minutes. The patient's had no shaking movements, headache, nausea, photophobia, or anxiety. She has a history of HTN and hypercholesterlima and takes amlodipine ad rosuvastatin. respectively. Her blood pressure is 125/70 mmHg and pulse is 78/min and regular. Neurologic examination is unremarkable. Fingerstick glucose is within normal limits. ECG shows normal sinus rhythm. Carotid Doppler reveals mind left common carotid artery stenosis. MRI of the brain and echocardiogram are unremarkable. If the patient is started on an additional medication that is indicated for her condition, which of the following adverse effect is most likely to occur?
This patient, with hypertension, hypercholeseteroliema, and sudden-onset neurologic deficits (eg. right arm weakness, difficulty speaking) that fully resolved within minutes, most likely had a
transient ischemic attack (TIA)
. In addition to optimal blood pressure control and statin therapy,
low dose aspirin
is common used to
prevent ischemic stroke
in patients with TIA.
> It works by irrevseribly acetylating/inhibiting the cyclooxyrgenase (COX) enzymes.
> At least 2 distinct COX-1 dependent mechanisms contribute to the increased risk of upper *gastrointestinal (GI) bleeding associated with aspirin therapy: Inhibition of platelet aggregation and impairment of prostaglandin-dependent GI mucosal protection. The risk of upper risk of upper GI bleeding increases with high doses but is increased 2-to 3-fold even with low-dose aspirin. Proton pump inhibitors can help reduce the risk of upper GI bleeding in patients taking aspirin.
Orthostatic hypotension may occur with use of antihypertensive medications due to vasodilation (eg. _______________) and volume depletion (eg ___________)
Vasodilation: nitrates, calcium calcium channel blockers)
Volume depletion: loop and thiazide diuretics
uWORLD: A research center studying cardiovascular pathology is conducting animal trials in which experimental rabbits are fed substances that alter connective tissue synthesis and modification. The animals are monitored for several weeks prior to euthanasia. At autospy myxomatous degeneration with pooling of proteoglycans in the media layer is obsessed in the arteries of these animals. These fines are associated with the pathogenesis of which of the following
> Myxomatous changes (pathologic weakening of connective tissue) in the media of large arteries are found in
cystic medial degeneration
. Medial degeneration is characterized by the
fragmentation of elastic tissue
("basket weave" pattern compared to normal) and a separation of the elastic and fibromuscular components of the tunica media by small, cleft-like spaces that become filled with amorphous extracellular matrix.
is a frequent cause of cystic medial degeneration in younger patients. It is characterized by an autosomal dominant defect in the extracellular glycoprotein fibrillin-1. Fibrillin-1 is a major component of extracellular matrix microfibrils, which form the scaffolding for elastic fibers. Mutations of the fibrillin-1 gene predisposes to
aortic aneurysms and dissections
uWORLD: A 34 yo man comes to the ED department with fatigue and lightheadedness. The patient had an upper respiratory infection last week, and since then his energy level has been low with shortness of breath of mild exertion. Otherwise, his medical history is insignificant. He is a lifetime nonsmoker. The patient's temperature is (98.6 F), blood pressure is 80/60 mmHg, and pulse is 120/min and regular. His pulse becomes undetectable to palpation during inspiration. The lungs are clear to auscultation, but the jugular veins are distended. Which of the following is the most likely diagnosis.
> This presentation of
jugular venous distention
with clear lungs, and
(manifesting as lost of palpable pulse during inspiration) is consistent with
. This is most likely due to the patient's recent viral illness causing viral pericarditis with significant pericardial fluid accumulation. Normally there is a <10 mmHg decrease in systolic blood pressure during inspiration.
refers to an abnormal exaggerated decrease in systolic blood pressure >10 mmHg on inspiration, and is a common finding in patients with pericardial effusion with cardiac tamponade.
uWORLD: A 37 yo man is found unresponsive under a tree during a thunderstorm. He is not breathing when paramedics arrive on the scene. On examination, his pupils are fixed and dilated. Several cutaneous erythematous marks in a fern-leaf pattern are seen on his lower extremities. Second-degree burns are present on both arms. Cardiopulmonary resuscitation is started; however, the patient does not respond and is pronounced dead on arrival at the hospital. Which of the following is most likely to be the primary cause of his death?
> Although lightning injures are rare, they are associated with a 25% fatality rate. Two-thirds of lightning-related deaths occur within the first hour after injury, with fatal arrhythmias and respiratory failure as the most common cause. patients with minor cutaneous involvement may still have major internal injury after lightning strikes and high-voltage electrical contact.
uWORLD: A 54 yo man with nonischemic cardiomyopathy comes to the office for a follow-up visit. He has been hospitalized frequently for acute decompensated heart failure., and currently has dyspnea on mild exertion. The patient also has a history of hypertension and takes multiple medications. Blood pressure is 116/70 mmHg, and pulse is 72/min and regular. Physical examination shows elevated jugular venous pressure, bibasilar lung crackles, and lower extremity edema. Serum creatinine is 1.0 mg/dL and serum potassium is 4.2 mEq/L. Three weeks after starting digoxin therapy, the patient reports symptomatic improvement. Which is the intimal cellular event triggering the response to the new medication?
Decreased sodium efflux from myocardial cells
> Digoxin directly inhibits the Na-K-ATPase pump in myocardial cells, leading to a decrease in sodium efflux and an increase in intracellular sodium levels. This reduces the forward activity of sodium-calcium exchanger, causing increased intracellular calcium concentration and improved myocyte contractility.
> The increase in intracellular sodium caused by digoxin reduces the forward activity of the sodium-calcium exchanger, resulting in increased intracellular calcium concentration. However, the calcium increase is a SECONDARY effect of digoxin that occurs after the increase in intracellular sodium
uWORLD: A 77 yo man comes to the office after he was found to have high blood pressure during a health fair. The patient denies any medical problems and feels proud that he has not needed to see a doctor for many years. His blood pressure is 170/70 mmHg and pulse is 74/min. Other physical examination findings are normal. The patient is started on a medication to treat his hypertension. During his follow-up visit 3 weeks later, he reports bilateral leg swelling. He has no chest pain, shortness of breath, or abdominal symptoms. His blood pressure is 135.65 mHg and pulse is 80/min. Cardiopulmonary examination is normal, but there is bilateral, symmetrical, 2+ pitting lower extremity edema. Laboratory studies show serum creatinine of 0.8 mg/dL, and urinalysis is negative for proteinuria. Which of the following is most likely prescribed to treat this patient's hypertension? (Amlodipine, Eplerenone, HTCZ, ramipril, torsemide)
> Amlodipine is a dihyropyridine calcium channel blocker commonly used as monotherpay or in combination with other agents for treatment of hypertension. Major side effects include headache, flushing, dizziness, and PERIPHERAL EDEMA
> Development of peripheral edema is related to preferential dilation of pre capillary vessels (arteriolar dilation), which leads to increased capillary hydrostatic pressure and fluid extravasation into the interstitum.
_____________________ is an aldosterone antagonist and functions similarly to spironolactone as a potassium-sparing diuretic. The most frequent side effects of this medication is hyperkalemia, increased creatinine, and gynecomastia (~1% versus 10% with spironolactone)
Loss of cardiomyocyte contractility occurs within ________________ after the onset of total ischemia. When ischemia lasts less than 30 minutes, restoration of blood flow leads to reversible contractile dysfunction (myocardial stunning), with contractility gradually returning to normal over the next several hours to days. However, after about 30 minutes of total ischemia, ischemic injury becomes irreversible.
A 39 yo woman suddenly collapses at home after experiencing severe chest pain and dies before reaching a hospital. Postmortem examination reveals an occluding thrombus overlying a ruptured atherosclerotic plaque on the left anterior descending artery. The patient is also found to have thickened mitral valve leaflets with multiple small vegetations on both valvular surfaces and fibrinoid necrosis of arterioles. Other findings include glomerular capillary basement membrane thickening with wire-loop changes. This patient was most likely suffering from which of the following conditions?
Systemic lupus erthermatosus
> Cardiovascular manifestations of lupus include accelerated atherosclerosis, small-vseel necrotizing vasculitis, pericarditis, and Libman-Sacks endocarditis (small, sterile vegetations on both sides of the valve). Renal involvement classically manifests as
diffuse proliferative glomerulonephritis
, which is characterized by diffuse thickening of the glomerular capillary walls with "wire-loop" structures on light microscopy.
uWORLD: A 71 yo man comes to the physician with a 2 month history of progressive exertion dyspnea. He can hardly walk half a block without stopping to catch his breath. He also has difficulty sleeping at night. Cardiac auscultation findings over the apex are given showing S3 sounds. The auscultatory findings most likely reflect which of the following?
Increased left ventricular end-systolic volume
> The third heart sound (S3) is a low-frequency sound occurring just after S2 that is commonly associated with increased left ventricular end-systolic volume, which occurs in the setting of left ventricular systolic failure.
> The S3 heart sound develop when there is an imbalance between the force with which blood is pushed into the ventricle and the ability of the ventricle to accommodate this blood flow.
Hypertrophic cardiomyopathy is a form of dynamic left ventricular outflow obstruction that is commonly associated with ______________, which would produce a systolic murmur
Bulging of the intraventricular septum occurs in cardiac tamponade when the accumulation of large quantities of pericardial fluid
prevents the expansion of the ventricular free walls
, venous blood return increases and the intraventricular septum buses into the left ventricle to allow the right ventricle to accommodate the increased blood volume. The resultant DECREASE in left ventricular filling produces the finding known as _____________
uWORLD: A 21 yo man comes o the office due to multiple episodes of syncope. The patient has no chest discomfort or dyspnea. He has no known medical problems and does not use tobacco, alcohol, or illicit drugs. The patient is a computer analyst and leads to mostly sedentary lifestyle. He reports that several family members have died of sudden cardiac death. Genetic analysis reveals an iron channel defect. Due to the defect, cardiac cells show decreased outward potassium flow and resultant prolongation of the action potential. Which of the following is the most likely consequence of this patient's disease?
Ventricular tachycardia and sudden death
> Congenital long QT syndrome is most often caused by
genetic mutations in a K+ channel protein that contributes to the outward-rectifying potassium current.
A decrease in the outward K+ current leads to prolongation of action potential duration and QT interval. This prolongation predisposes to the development of life-threatening ventricular arrhythmias (eg, tornadoes de pointes) that can cause palpitations, syncope, seizures, or sudden cardiac death.
uWORLD: In experiments, transient myocardial ischemia causes myocardial cells to increase in size. This effect is due in part to which of the following?
(Intracellular K+ accumulation, intracellular Ca2_ accumulation, High cellular HCO3- content, Cascade protein phosphorylation, Net cellular solute loss)
Intracellular Ca2_ accumulation
> Ion pump failure due to ATP deficiency during cardiac ischemia causes intracellular accumulation of Na+ and Ca2+. The increased intracellular solute concentration draws free water into the cell, causing the cellular and mitochondrial swelling that is observed histologically.
uWORLD: A 4 yo boy is brought in by his parents for evaluation of a fever that has persisted for the past 5 days. He has also been more irritable than usual and had 2 or 3 episodes of vomiting. The patient has no prior medical problems and takes no medications. He has received all recommended vaccinations. he traveled to China last year to visit his grandparents and cousins but has not traveled outside of the country this year. Temperature is 38.9 C (102 F). Physical examination shows bilateral conjunctival injection with no exudates. His tongue is bright red and lips are cracked. Non pitting edema is present on his hands and feet. Which of the following complications is this patient at greatest risk for developing?
Coronary artery aneurysm
> Kawasaki disease is a vasculitis of medium-sized arteries that presents with persistent fever for > 5 days, bilateral conjunctivitis, cervical lymphadenopathy, and mucocutaneous involvement. Coronary artery aneurysms are a series complication of Kawasaki disease.
uWORLD: A 58 yo man comes to the ED with abrupt-onset, severe chest pain that radiates to his back. His blood pressure is 220/130 mmHg in the left arm and 180/100 mmHg in the right. His heart rate is 100/min. Initial laboratory studies show normal serum troponin levels. Electrocardiogram is negative for ST-segment changes. This patient's acute condition was most like triggered by which of the following events?
classically presents with severe retrosternal pain that
radiates to the back
. This condition develops when overwhelming hemodynamic stress leads to tearing of the aortic intimal with blood subsequently dissecting through the aortic media. The resulting intramural hematoma can extend both proximally and distally and can compress major arterial branches and impair blood flow.
> An intimal fatty streak is the intimal lesion of atherosclerosis. Some fatty streaks progress to frank atheroma, which can progressively weaken the underlying media of the aortic wall. However, atherosclerosis predisposes more to
Aortic aneurysm formation
than to aortic dissection.
uWORLD; A 32 yo Caucasian male experiences fever, weight loss, myalgia, and abdominal pain. His blood pressure is 150/90 mmHg, and his heart rate is 90/min. If diagnosed with polyarteritis nodosa (PAN), which of the following arteries will most likely be spared by the disease?
> PAN is segmenta;, transmural, necrotizing inflammation of medium-to-small-sized arteries. Renal artery invovlemtn is often prominent. Vessels of the kidneys, heart, liver, and GI tract are most commonly involved in resulting ischemia, infarction, or hemorrhage. Cutaneous manifestations occur in up to one-third of patients, and include palpable purpura. The lung is very rarely involved.
uWORLD: A 68 yo man comes to the office due to several weeks of progressive exertion dyspnea and lower extremity edema. Medical history is significant for non-Hodgkin lymphoma, which is in remission after chemotherapy 8 years ago. Blood pressure is 126/76 and pulse is 88/min. Auscultation reveals bibasliar lung crackles and 1+ bilateral lower extremity edema. Echocardiogram shows biventrciular dilation and a left ventricular ejection fraction of 35%. Stress myocardial perfusion scan is negative for inducible ischemia. After initial stabilization, long-term use of which of the following medications will most likely improve survival in this patient?
(Amidarone, Amlodipine, Carvedilol, Digoxin, Diltiazem, Flecainide, Furosemide)
> Drugs that have been shown to improve long-term survival in patients with heart failure due to left ventricular systolic dysfunction include beta blockers, ACE inhibitors, angiotensin II receptor blockers, and aldosterone antagonists.
> This patient's clinical presentation is consistent with
decompenstated systolic heart failure
(HF) due to nonischemic cardiomyopathy, likely as a result of chemotherapy for non-Hodgkin lymphoma.
After initial stabilization
, long-term use of
(eg. carvedilol, metoprolol) has bene shown to improve survival in patients with HF due to left ventricular systolic dysfunction.
> Beta blockage decrease myocardial work and oxygen demand by slowing the ventricular rate and reducing contractility.
> Beta blockers should not be initiated in patients with unstable (decompensated) HF, as they can further impair cardiac output; they should be introduced slowly after the patient has been stabilized.
uWORLD: A 68 yo Caucasian male presents with chewing difficulty and persistent headaches of recent onset. On physical examination, there is tenderness over the patient's temples. You proceed with an artery biopsy. The morphologic changes observed in this patient's arteries are most similar to those of which of the following?
> This patient presents with symptoms consistent with giant cell (temporal) arteritis (GCA). Jaw claudication is the most specific symptom of GCA. Headache, facial pain, and vision loss are common symptoms as well. Temporal artery biopsy demonstrates granulomatous inflammation of the media. GCA tends to develop in patients older than 50.
Takaysau arteritis is MOST SIMILAR TO GCA
> Takayasu arteritis and temporal arteritis involve arterial vessels of different sizes and locations (aorta and proximal aortic arterial branch involvement versus more distal carotid artery branch involvement, respectively), and have different clinical presentations. Even so, they may share a common pathologic morphology, consisting of
Granulomatous inflammation of the media
An 8 yo boy who recently moved to the US from Indonesia is brought to the ED with fever, throat pain, and difficulty breathing. His immunization status cannot be determined. Examination of his threat shows extensive, coalescing gray pharyngeal exudates and cervical adenopathy. Several days after being admitted to the hsotpaiol, he dies of myocarditis and severe heart failure. The present elf which of the following would most likely have prevented this patient's death?
IgG against circulating proteins
> Corynebacterium diphtheria causes diphtheria, an acute bacterial dissese that initially affects the oropharynx. The organism is spread by respiratory droplet transmission and causes disease via its A/B exotoxin. The B (think: binding) subunits allows penetration of the A (think: alive) subunit into the cell to inhibit ribosome function. Neural and cardiac toxicity are serious potential sequelae.
> Immunization with diphtheria toxoid induces production of circulating IgG against the exotoxin B subunit, effectively preventing disease.
uWORLD: A 46 yo woman comes to the physician with easy fatiguability and exertional dyspnea. Cardiac auscultation reveals a diminished first heat sound and apical holosystolic murmur radiating to the axilla. Diffuse pulmonary crackles are heard bilaterally. There is no elevation of jugular venous pressure or peripheral edema. Which of the following would most likely increase the ratio of forward flow volume to regurgitant flow volume in this patient?
Decreasing left ventricular after load
> Left ventricular after load is a major determinant of the forward-toregurigant flow ratio in patients with mitral regurgitation. Decreasing after load will increase forward flow ill reducing regurgitant flow. An increase in left ventricular and diastolic volume can contribute to or worsen mitral regurgitation when the degree of regurgitation is dependent on left ventricular size (eg. in dilated cardiomyopathy).
For class I antiarrhymatics, sodium-channel-binding strength is IC > IA > IB.
describes the phenomenon in which
higher heart rates lead to increased sodium channel blockade due to cumulative blocking effects over multiple cardiac cycles
. Class IC antiarrhythmics demonstrate the ______________ use dependence due to their slow dissociation from the receptor, and class IB drugs have the ___________ use dependence as they rapidly dissociate.
A 75 yo man is brought to the ED by paramedics following a high-spend motor vehicle accident.t Several attempts are made to resuscitate him but are unsuccessful. The patient and no significant past medical history and took no medications. He was known to be good in health and tolerant of moderate levels of physical activity. Electrocardiogram findings at his office visit shoed no abnormalities. At autospy, head claficaitons of the aortic valve are seen. Which of the following most likely precede the aortic valve changes observed in this patient?
> Dystrophic calcification occurs in damaged or nitric tissue in the setting of normal calcium levels; metazoic calcification occurs in normal tissue in the setting of hypercalcemia
> Pathologic cell hypertrophy of left ventricular cardiomyoctyes (i.e left ventricular hypertrophy) can occur as the result of severe aortic stenosis
uWORLD: A 64 yo man dies while hospitalized for dyspnea. His wife reports several prior episodes of dyspnea and cough. he has a history of hypertension and smoked a pack of cigarettes daily for 38 years. He immigrated to the US 20 years ago. Light microscopic examination of his lungs rivals macrophages containing golden cytoplasmic granules that turn dark bleu Prussian blue staining. Which of the following conditions is most likely associated with this patin's microscopic findings?
Left ventricular dysfunction
> The presence of hemosiderin-laden macrophage in pulmonary alveoli indicates chronic elevation of pulmonary capillary hydrostatic pressures, most commonly as a surest of left-sided heart failure.
uWORLD: A 32 yo man comes to the ED with sharp mid-chest pain that increases with deep inspirations and decreases when he sits up. He has no significant medical history aside from a mild respiratory illness one week ago. His blood pressure is 120/70 mmHg and his pulse is 110/min. Which of the following findings do you most expect in this patient?
> Acute-onset, mid-chest pleuritic pain that decrease on sitting up and leaning forward is characteristic of acute pericarditis. Fibrinous or serofibrinous pericarditis is the most common form. Pericardial friction rub is the most striking physical finding.
> The chest pain of acute pericarditis is sharp and pleuritic in nature, and characteristically decreases when the patient sits up and leans forward (as this maneuver decreases the pressure on the parietal pericardium). Fibrinous or serofibrinous pericarditis is the most common variant, and the pericardial friction rub (described as high pitched, leathery, and scratchy) is the most striking physical finding.
> In most instances, this type of pericarditis is caused by myocardial infarction, rheumatic fever, or uremia; although a viral infection may occasionally cause a fibrinous exudate to accumulate in the pericardial space. The patient's history of a recent upper respiratory illness suggests the the has acute pericarditis due to an infectious cause.
The space of a ________ heart sound reflects a rapid rate of diastolic ventricular filling with a large volume of blood (as in ventricular volume overload) and/or reduced ventricular compliance (diastolic dysfunction).
Autospy reveals significant
thickening of the right ventricular free wall
(almost 2 cm in thickness; normal; 3-4 mm) compared to the left ventricle. This finding of severe right ventricular hypertrophy in a young woman with
and sudden death is suggestive of ____________________
Pulmonary arterial hypertension (PAH)
> Pulmonary hypertension can caused by a number of conditions, including chronic lung disease and left heart failure.
uWORLD: A 65 yo immigrant from Eastern Europe comes to the physician because of afoul-week history of low-grade fever, multiple joint pains, and a well-demarcated erythematous rash on his face and trunk. The patient denies hair loss, mucosal ulceration, or photosensitivity. His serum test is motive for the presence of anti-nuclear antibody (ANA) in very high titers. The patient reports a past medical history of coronary artery disease, congestive heart failure, and "cardiac rhyme abnormalities ." This patient should be specifically questioned about the intake of which of the following medications?
(Amiodarone, propranolol, lidocaine, procainamide, verapamil, adenosine)
have the highest risk of causing drug-induced lupus erythematous (DILE), which is characterized by development of lupus-like symptoms in addition to positive ANA and anti-histone antibodies. Unlike with SLE, anti-dsDNA antibodies are rarely seen.
> Procainamide is metabolized via hepatic acetylation. Individuals who are "slow acetylators" are at greatest risk for DILE, while individuals who metabolize the drug more rapidly are less like to experience this adverse adverse effect.
uWORLD: A 60 yo Caucasian male is diagnosed with exertion angina. His treatment regimen includes metoprolol, isosorbide denigrate and aspirin. He takes isosorbide denigrate early in the morning and again in the afternoon, but he does not take an evening dose. Such a pattern of drug administration is intended to decrease which of the following?
> Around-the-clock nitrate administration (in any form) rapidly results in development of tolerance to nitrates. This is why nitrate-free interval must be provided every day in patients that are using daily long acting nitrates.
> The mechanism by which this occurs has not been fully demonstrated.
> Usually the nitrate-free period is timed to occur during the night when the patient is sleeping and cardiac work is the least.
uWORLD: A 30 yo male presents to the ED with complaints of fever, chills, and generalized malaise. The patient has no significant past medical or surgical history. On further questioning, the patient admits to smoking one pack of cigarettes a day, consuming 8-10 alcoholic beverages a week, and using illicit drugs intravenously on a regular basis. he is febrile and tachycardia. Auscultations of his heart reveals a faint murmur. A preliminary diagnosis of infective endocarditis is established and blood is sent for laboratory evaluations, including cultures. Blood cultures grew enterococci strains. Enterococci strains isolated from this patient are known to be substitute D-lactate for D-alanine in the synthesis of pentapeptide proteoglycan precursors. This substation decreases pentapeptide binding for which of the following antibiotics.
(Vancomycin, penicillin, cycloserine, polymyxin, tetracycline, amikacin)
> The mechanism of vancomycin resistance in organisms such as VRE (Vanocoycin Resistant Enterococcus) is a substitution of D-lactate in the place of D-alanine during the process of peptidoglycan cell wall synthesis. This prevents the binding of vancomycin to its usual D-alanyl-D-alanine binding site in the cell wall.
________________ binds to, disrupt, and interferes with the permeability of the cytoplasmic membrane.
____________________ is an inhibitor of protein synthesis that binds to the 30S subunit and inhibits binding of amnioacyl-tRNAs.
The mechanism of resistance include an increased efflux of drug from within the bacterial cell via an active-efflux pump mechanism or production of a protein that allows translation to take place even when this is present within the bacterium.
Cortisol exerts a ___________ effect on many hormones to help improve the response to a variety of stressors. For example, cortisol increases vascular and bronchial smooth muscle reactivity to catecholamines and increases glucose release by the liver in response to glucagon.
> Permissiveness occurs when one hormone allows another to exert its maximal effect.
uWORLD: A 62 yo man who underwent mitral valve replacement 1 month ago is being evaluated in the ED for low-grade fevers. He has some malaise and dyspnea. Multiple sets of blood cultures are drawn and, within hours, all bottles grow gram-positive cocci in clusters that are catalase-costive and coagulase-negative. The decision is made to begin empiric antibiotic therapy. Initial empiric treatment should include which of the following antibiotics?
(Ceftriaxone, ciprofoxacin, clindamycin, nafcillin, penicllin G)
> This is consistent with infection due to
coagulase-negative staphylococci (CoNS). These organism produce a polysaccharide
slime* facilitating prosthetic device adherence.
> For example, Saphylococcus epidermis (a type of CoNS) can cause an indolent endocarditis following valve replacement.
> Initial empiric treatment of coagulase-negative staphylococcal infection should include vancomycin due to widespread methicillin resistance, especially in nosocomial infections. If susceptibility results indicate a methicillin-susceptible isolate, vancomycin can be switched to nafcillin or oxacillin.
uWORLD: A 40 yo female with a history of depression and hypertension is brought to the ER after being found obtunded in her apartment. She is hypotensive and bradycardia on physical examination. Intravenous glucagon is administered, and her condition improves. Which of the following intracellular changes is most likely responsible for the improvement in her condition?
Increased cAMP in cardiac myocytes
> Patients who have overdosed on beta blockers should be treated with glucagon, which increases heart rate and contractility independent of adrenergic receptors. Glucagon activates G-protein-coupled receptors on cardiac myocytes, causing activation and adenylate cyclase and raising intracellular cAMP. The result is calcium release from intracellular stores and increased sinoatrial node firing.
> Glucagon is the drug of choice for beta blocker overdose.
uWORLD: A 24 yo male presents to the ED with sudden onset of palpitations. He had an episode similar to this one year ago that resolved spontaneously. Rapid IV injection of a drug into this patient results in instantaneous resolution of the arrhythmia but is accompanied with transitory flushing burning in the chest and shortness of breath. Which of the following drugs was used to treat this patient's condition?
(Amiodarone, lidocaine, procainamide, verapamil, adenosine, digoxin)
> Adenosine is a rapidly acting antiarrhymic used to quickly convert people out of PSVT (drug of choice). It is also rapidly cleared and has a half-life of only less than 10 seconds. It commonly causes chest burning (bronchospasm), flushing and high grade block as adverse reactions (remember, this is the drug used for chemical stress tests!)
uWORLD: A 52 yo male is having low-grade fevers after recent replacement of his aortic valve. Repeated blood cultures grow gram-positive cocci. Which of the following characteristics is most consistent with Staphylococcus epidermis as the cause of this patient's symptoms?
> Staphylococcus epidermidi and S. saprophytic are both coagulase-negative staphylococci species. Staphylococcus epidermis is the most common cause of infective endocarditis in patients with prosthetic valves and septic arthritis with prosthetic joints. It is suspecible to novobiocin.
All Staphylococci are catalase- ________________ and streptococci are catalase-__________________
Mannitol fermentino is a property of _________________. The other Staphylococci are not able to ferment mannitol.
Novobiocin resistance is a property of _________________________; this is the property that allows it to be differentiated from other coagulase-negative Staphylococci.
uWORLD: A 52 yo man comes to the physician with concerns about a "heart problem". He feels fine, but was told to see a physician after a heart murmur was detected ruing a wellness fair at work. Physical examination reveals a holosystolic murmur best heard at the apex of the heart that radiates to the axilla. The remainder of his physical examination is normal. Which of the following is the best indicator of the severity of this patient's problem?
Presence of audible S3
> In a patient with mitral regurgitation (MR), the most reliable auscultatory finding indicating a high regurgitant volume (severe MR) and left ventricular volume overload is a left-sided S3 gallop. The intensity of the holosytolic mummer does not correlate well with regurgitant volume as larger regurgitant orifices often present with softer murmurs.
The S2 to opening snap interval is a diastolic time interval between the closure of the aortic valve (A2) and the abrupt halting of leaflet motion during opening of a stenotic mitral valve (the opening snap). It is an indicator of the severity of ____________________, not mitral regurgitation.
____________________ is caused by decreased ventricular compliance and is characterized by normal left ventricular (LV) ejection fraction, normal LV end-diastolic volume, and elevated LV filling pressures.
Hypertension, obesity, and infiltrative disorders (eg. transthyretin-related amyloidosis, sarcoidosis) are important causes of this.
Diastolic heart failure (DHF)
___________________ is typically characterized by increased LV volume and shifting of the pressure-volume curve to the right due to thinning of the vehicular wall (increased compliance)
Systolic heart failure
> Alcoholic cardiomyopathy, doxorubicin therapy, selenium deficiency, and viral myocarditis can all lead to DILATED cardiomyopathy with LV systolic dysfunction.
______________________, a protein tetramer produced in the liver, acts as a carrier of thyroxine and retinol. Mutations in the gene can increase the tendency of it to misfiled, producing an
that infiltrates the myocardium (
Nitroglycerin is primarily a _________________. It decreases preload which decreases myocardial oxygen and thereby treats angina pectoris.
> Therefore, it has its most effect on the large veins.
Hypertrophic cardiomyopathy is almost associated with _________________ secondary to impaired mitral valve closure, which would produce a systolic murmur as opposed to the diastolic murmur head in this case.
uWORLD: A 75 yo man comes to the office due to worsening dyspnea and fatigue on exertion over the last 6 months. Recently, he has bad severe lightheadedness during physical activity. Blood pressure is 125/65 mmHg and pulse is 65/min and regular. Physical examination reveals a harsh ejection-type
Extensive valve calcification with impaired leaflet mobility
> Calcific degeneration of the trileaflet aortic valve is the most common cause of aortic stenosis (AS) in developed nations. AS is characterized by progressive aortic valve leaflet thickening and calficiaiton, leading to restricted leaflet excursion and mobility. AS murmur is usually a harsh ejection-type systolic murmur heard best at the base of the heart in the "aortic area" (second right intercostal space) with radiation to the carotid arteries.
Myxomatous degeneration of the mitral valve leaflets leads to ____________________. Cardiac auscultation usually reveals a non-ejection click and milk-to-late systolic murmur of mitral regurgitation
Mitral valve prolapse
uWORLD: A 68 yo man is brought to the ED with chest pain. He has had exertion chest pain for the last year that has progressively worsened. He was shoveling snow earlier this morning when his chest pain became unbearable. An electrocardiogram shows ST and T wave changes suggestive of ischemia. Cardiac enzymes are elevated. Emergent coronary angiography is performed, which demonstrates significant atherosclerotic involvement of the left anterior descending and circumflex arteries. Which of the following provides major proliferative stimuli for the cellular components of atherosclerotic plaques?
>In the pathogenesis of atherosclerotic plaques, release of platelet-derived growth factor (PDGF) by locally adherent platelets, endothelial cells, and macrophages promotes the migration of smooth muscle cells from the media into the intimal and their subsequent proliferation.
uWORLD: A 44 yo man with a history of IV drug use came to the ED with fevers and chills. multiple sets of blood cultures were positive for Staphylococcus aureus, and the patient was diagnosed with infective endocarditis. He was successful treated with a long course of antibiotics. Three months later, he return to the clinic for a follow-up evaluation. The patient has no current symptoms are report good exercise tolerance. Echocardiogram shows severe aortic regurgitation as a sequela to the prior infection. Which of the following changes is most likely responsible for maintaining cardiac output in the setting of this valvular abnormality?
Increased in left ventricular stroke volume
> This patient has developed
chronic severe aortic regurgitation
(AR) as a consequence of infective endocarditis.
> The regurgitant blood flow increases left ventricular end-diastolic volume (
) and wall stress, with resultant
> The gradual increase in left ventricular chamber size due to eccentric hypertrophy
increases stroke volume
and maintains cardiac output.
uWORLD: A 55 yo man being treated for depression is brought to the ED with severe confusion and hallucinations. His wife found him when she came home early from work. She found an empty bottle of pills in the bathroom but forgot to bring it in her rush to the hospital. On examination, the patient's blood pressure is 80/60 mmHg and pulse is 100/min. His mouth is dry, and his face is flushed. ECG shows QRS prolongation and frequent premature ventricular beats. Initial laboratory studies are obtained, and intravenous hydration is started. With of the following agents would best correct this patient's cardiac abnormalities? (Acetylcysteine, atropine, flumazenil, naloxone, potassium solution, propranolol, sodium bicarbonate)
> Tricyclic antidepressant (TCA) overdoes can present with delirium, seizures, cardiac abnormalities (arrhythmias, conduction delays), severe hypertension, and signs of anticholinergic toxicity (hyperthermia, flushing, dry mouth, urinary retention).
> Symptoms of overdose are caused by blockage of
cardiac fast sodium channels
and inhibition of muscarinic acetylcholine, histamine, and alpha-1 adrenergic receptors.
> Sodium bicarbonate is used to treat associated cardiac toxicity and works by increasing serum pH and extracellular sodium (alleviating fast sodium channel blockade)
_________________ is used for organophosphate (cholinergic) poisoning. Acute cholinergic toxicity presents with bradycardia, diarrhea, muscle weakness, seizures, and coma.
QRS prolongation and severe hypotension are not present.
________________ is a rapidly acting opioid antagonist that is used for opioid overdose, which typically presents with miosis and reparatory and central nervous system depression.
uWORLD: A 54 yo Caucasian male complains of "dizzy spells" when walking his dog in the morning. He denies any chest pain, shortness of breath, weakness, or headaches. Cardiac auscultations findings at the right sternal border are given below. Which of the following is the most likely cause of this patient's symptoms.
Bicuspid aortic valve
> A bicuspid aortic valve is a common cause of aortic stenosis in the US. The classic auscultatory finding in patients with aortic stenosis is a harsh, crescendo-decrescendo systolic ejection murmur heard best in the right second intercostal space with radiation to the carotids.
uWORLD: A 63 yo man comes to the office with exertion dyspnea the thats been progressing over the last 3 weeks. He sleeps in a recliner with his head elevated as he gets short of breath when laying flat in bed. His past medical history includes gout, dyslipidemia, and hypertension. On examination, blood pressure is 154/89 mmHg and pulse is 85/min. Distended jugular veins are seen in the semirecumbent position. An apical heave is found on cardiac examination. Pitting edema is evident in the bilateral lower extremities. Levels of which of the following substances will be higher in the pulmonary vein compared to the pulmonary artery in this patient?
> Heart failure results in stimulation of the sympathetic nervous system and the renin-angiotensin-aldosterone system in an attempt to maintain effective intravascular volume. Inactive angiotensin I is converted into active angiotensin II by endothelial-bound angiotensin-converting enzyme in the small vessels of the lungs.
uWORLD: a 68 yo man comes to the office due to high and leg pain that worsens with exertion. He is unable to walk through the local mall with his wife without discomfort. Past medical history is significant for hypertension and diabetes mellitus. The patient smokes 2 packs of cigarettes a day and consumes alcohol occasionally. Physical examination of the extremities show weak dorsals pedis pulses in both feet. Further evaluation confirms moderate peripheral arterial disease involving both lower extremities. Which of the following drugs would best provide symptomatic improvement due to direct dilation of arteries and inhibitor of platelet aggregation?
(Abciximab, argatroban, aspirin, cilostazol, heparin, tissue plasminogen activator, warfarin)
> Symptomatic management of peripheral artery disease (PAD) includes a graded exercise program and cilostazol.
is a phosphodiesterase inhibitor that inhibits platelet aggregation and acts as a direct arterial vasodilator. Patients with PAD should also receive an anti platelet agent (aspirin or clopidogrel) for secondary presentation of coronary heart disease and stroke.
Micro emboli from the valvular vegetations of
are the most common cause of subungual ______________________. The presence of these lesions necessitates careful cardiac auscultation to detect a possible new-inset regurgitant murmur.
uWORLD: A 34 yo Asian female is hospitalized with progressive exertion dyspnea, lower extremity edema and cough. She also describes frequent nocturnal episodes of breathlessness and recent hoarseness. She does not use tobacco, alcohol or drugs. Auscultation reveals loud first and second heart sounds and a mid-diastolic rumble best heard at the cardiac apex. This patent's hoarseness is most likely caused by:
> Left atrial enlargement can sometimes cause left recurrent laryngeal nerve impingement. Neurapraxia resulting in left vocal cord paresis and hoarseness may result.
uWORLD: A 53 yo man comes to the ED due to fever and progressive weakness over the last 2 weeks. Yesterday, he also developed shortness of breath. The patient emigrated from Eastern Europe 2 years ago and says he was diagnosed with "heart disease" in the distant past, but he does not really any details. He does not use tobacco, alcohol or illicit drugs. Despite receiving appropriate medical care, the patient expires during hospitalization. On autopsy, gross examination of his heart shows large, friable masses on the mitral valve with extensive destruction of cuspal tissue.
Valvular inflammation and scarring
> Chronic valvular inflammation and scarring associated with rheumatic heart disease predisposes to an increased risk of infective endocarditis, which is characterized by valvular vegetations with destruction of the underlying cardiac tissue.
uWORLD: The blood cultures obtained from the patient on admission grow Streptococcus species. Which of the following processes was the most likely imitating step in the pathogenesis of this patient's condition?
> Vegetations are caused by bacterial colonization and growth on
sterile fibrin-platelet nidus
that forms on the damaged/disrupted endothelial surface of the valvular apparatus.
uWORLD: A 65 yo man comes to the physician after missing a follow-up appointment for CHF. He missed his appointment due to an upset stomach that will not go away. A detailed history reveals disturbed color perception, anorexia, nausea, vomiting, and diarrhea that have worsened over the past 2 weeks. His congestive heart failure has thus far been controlled effectively with multiple medications. If the cause of this patients current symptoms is not treated, which of the following complications is most likely to develop
> Digoxin toxicity presents with nonspecific gastrointestinal (eg, anorexia, nausea, vomitting) and neurologic (eg. fatigue, confusion, weakness) symptoms. Changes in color vision are a more common but rarer, finding. Left-threatening ventricular arrhythmias are the most serious complication. a
uWORLD: A 42 yo woman is brought to the hospital due to right-sided weakness and difficulty speaking. She has a longstanding history of a diastolic murmur, but her medical follow-up has been poor. She does not use tobacco, alcohol, or illicit drugs. A CT scan of the brain reveals a large ischemic stroke involving the left middle cerebral artery distribution. The patient dies 2 days later due to progressive neurologic deterioration. At autospy, exploration of the left atrium shows diffuse fibrous thickening and distortion of the mitral valve leaflets, commissural fusion at the leaflet edges, and narrowing of the mitral valve office. This finding is most likely the result of which of the following conditions?
> Rheumatic mitral stenosis is characterized by diffuse fibrous thickening and distortion of the mitral valve leaflets along with commissural fusion at the leaflet edges. Patients often present with a diastolic murmur, dyspnea, and fatigue and are at increased risk of atrial fibrillation and thromboembolism (eg, stroke)
uWORLD: A 42 yo man comes to the ED due to acute onset of SOB. The patient has excellent exercise tolerance and no medical problems. He does not use alcohol, tobacco, or illicit drugs. His family history is insignificant. Blood pressure is 98.60 mmHg and pulse is 112/min and regular. A short systolic murmur is head at the apex. Bilateral crackles are present on lung auscultation. Bedside echocardiography reveals a flail posterior mitral leaflet due to chordal rupture and severe mitral regurgitation. Which of the following best reflect this patient's cardiac hemodynamic compared to the normal heart? (After load, preload, and left ventricular ejection fraction)
After load decreases, preload increases, left ventricular ejection fraction increase
> Regurgitant flow into the left atrium in acute mitral regurgitation leads to increased left atrial pressure and increased left ventricular end-diastolic volume (preload).
The low-resistance regurgitant pathway also decreases left ventricular after load, end-systolic volume, and forward stroke volume
. Increased left atrial pressure and decreased cardiac output result in pulmonary congestion and severe hypotension, respectively.
uWORLD: A 34 yo woman has recurrent throbbing headaches that occur several times a month and cause significant distress. They are accompanied by nausea and photophobia. She has had 5 emergency department visits for those headaches over the last 6 months. During office visits, her blood pressure rangers form 140/90 mmHg to 150/95 mmHg. Neurologic examination is unremarkable. The patient is prescribed metoprolol and is advised that the medication is expected to decrease the frequency of headaches and also lower blood pressure in the long term. Which of the following best explains this medication's effect on blood pressure?
Decreased level of circulating renin
Beta blockers inhibit release of renin
from renal juxtaglomerular cells through antagonism of beta-1 receptors on these cells. Inhibition of renin release prevents activation of the renin-angiotensin-aldosterone pathway, which results in decreased vasoconstriction and decreased renal sodium and water retention.
uWORLD: A 32 yo man is brought to the ED with a several-day history of high-grade fever, dyspnea, and fatigue. The patient's temperature is 39.4 C (102.9 F), blood pressure is 122/70 mmHg, and pulse is 102/min and regular. Physical examination reveals a new holosytolic murmur with a blowing quality that is best head over the cardiac apex. Skin examination shows nontender lesions on the sole of the feet. Which of the following do these lesions most likely represent.
Micro emboli to skin vessels
are nontender, macular, and erythematous lesions typically located on the palms and soles of patients with acute
and are the result of specific embolization from valvular vegetations.
> Olser nodes are tender, violaceous nodules typically located in the pulp of finger and toes. The pathogenesis of Osler nodes is immune-complex deposition in the skin.
uWORLD: A 72 yo man is brought to the hospital due to severe substernal chest pain and SOB for the last several hours. The pain started suddenly when he was outside working in the garden. Medical hoister includes diet-controlled diabetes mellitus and hypertension. Physical examination reveals bilateral crackles and a third heart sound. ECG shows ST elevation in multiple leads. The patient is diagnosed with an acute myocardial infarction complicated by acute severe heart failure. He is started on dobutamine infusion and prepared for coronary catheterization. Which of the following is most likely to be increased due to the medication used in this patient?
Myocardial oxygen consumption
> Dobutamine is a beta adrenergic agonist with predominant activity on beta-1 receptors. It causes an increase in heart rate and cardiac contractility, leading to an increase in myocardial oxygen consumption.
uWORLDL The autospy of a 78 yo Caucasian male who died of esophageal cancer reveals a small heart without significant coronary artery atherosclerosis. Myocardial cells show prominent intracytoplasmic granules that are tinged yellowish-brown. Which accounts for this change?
> Lipofuscin is the product of lipid peroxidation, accumulating in aging cells (especially in patients with malnutrition and cachexia)
uWORLD: Coronary angiography of a 69 yo Caucasian female with chronic atypical chest pain shows extensive atherosclerosis and near-total occlusion of th left anterior descending (LAD) artery. The absence of myocardial necrosis and scarring despite vessel occlusion in the patient can best be explained by which of the following features of the occluding plaque?
Slow growth rate
> The major determinant of whether or not a coronary artery plaque will cause ischemic myocardial injury is the rate at which it occludes the involved artery. A slowly developing occlusion would allow for formation of collaterals that could prevent myocardial necrosis. A thin fibrous cap, a rich lipid cord, and activate inflammation in the atheroma would all decrease plaque stability and thus potentially promote rapid coronary occlusion via superimposed thrombosis if the plaque were to rupture.
uWORLD: A 44 yo man is evaluated in the clinic for occasional chest discomfort that is not consistently related to exertion. The patient's past medical history is significant for HTN and hyperlipidemia. His grandfather experienced a MI at age 50. Coronary CT angiography reveals several non obstructive atherosclerotic plaques in the coronary arteries. One plaque in the proximal left anterior descending artery appears extensive, has a large hypotenuse core, and occupies 40% of the lumen. No intervention is performed. One year later, the patient comes to the ED with acute severe chest pain and is found to have thrombotic occlusion of the proximal left anther descending artery. High intraplaque activity of which of the following enzymes most likely resulted in this patient's myocardial infraction?
> The likelihood of plaque rupture is related to plaque stability rather than plaque size or the degree of luminal narrowing. Plaque stability largely depends on the mechanical strength of the fibrous cap. Inflammatory macrophages in the intimal may reduce plaque stability by secreting metalloproteinases, which degrade extracellular matrix proteins (Eg, collagen)
> Activated macrophages infiltrating the atheroma contribute to the breakdown of extracellular matrix proteins (eg, collagen) by secreting
Cutaneous, strawberry-type capillary ___________________ are common, benign, congenital tumors, which are composed of encapsulated aggregates of closely packed, thin-walled capillaries. Initially, strawberry color rash grow in proportion to the growth of the child, before eventually regressing. In 75-95% of cases, the vascular tumor will regress completely by age 7.
First increase in size and then regress
uWORLD: A 56 yo man is admitted to a tertiary care center after being involved in a high-speed motor vehicle accident. The patient was thrown form his vehicle and suffered severe head trauma along with multiple fractures involving his ribs and extremities. Despite aggressive treatment, the dies the following day from massive cerebral edema and brainstorm hernitaiton. Autospy shows the following heart findings:
Left atrium: Enlarged
Left ventricular myocardial mass: increased
Left ventricular wall thickness: Increased.
The structural changes observed in this patient's heart are most likely associated with which of the following conditions?
Aging is associated with a decrease in LV chamber size
, predominantly through shortening of the apex-to-base dimension accompanied by a leftward bowing of the lower inter ventricular (sigmoid) septum. The aortic valve may also become calcified, resulting in aortic stenosis; however, structural cardiac changes due to aging are generally not prominent before age 65.
Mitral insufficiency causes LV ___________ as regurgitant flow through the mitral valve during systole increases the amount of blood returning to the LV during diastole. The net structural consequence of mitral insufficiency is enlargement of the LV cavity and eccentric hypertrophy.
uWORLD: A 24 yo woman comes to the ED due to left leg swelling and pain for the past 2 days. The patient is at 14 weeks gestation and has had an uneventful pregnancy to date. She has no chest pain or shortness of breath. The patient's pat medical history is otherwise unremarkable. She is a lifetime nonsmoker. Physical examination shows 1+ edema of the left lower extremity to the knee, associated with mild erythema. The patient's left calf diameter measures 3 cm greater than the right. Duplex ultrasound examination is consistent with left popliteal and femoral vein thrombosis. Her serum creatinine level is 0.7 mg/dL. Which of the following is the best treatment option for this patient?
(Apixaban, Clopidogrel, Dabigatran, Enoxaparin, Low-dose aspirin, Tissue plasminogen activator, Warfarin)
> Pregnancy increases the risk of
venous thromboembolic disease
(VTE) due to increased venous stasis, endothelial injury, and hyper coagulability. The risks and benefits to both mother and child need to be balanced, and
low-molecular-weight heparins such as enoxaparin
are the best treatment choice, especially during the early stages of pregnancy.
> Clopidogrel and aspirin have NO ROLE in the acute VTE treatment. Clopidogrel, which blocks platelet adenosine diphosphate receptor and limits platelet aggregation, is used in treatment of coronary artery disease and acute coronary syndrome syndrome and prevention of recurrent ischemic strokes. Low-dose aspirin is prescribed to certain pregnant patients at risk of preeclampsia.
> Heparins do NOT cross the placenta (low risk of teratogenicity and fetal hemorrhage).
uWORLD: A 60 yo man comes to the hostpial with chest pain. He has had intermittent squeezing, substernal pain over the last 3 days that is now sustained. The patient has no associated palpitations, lightheadedness, or shortness of breath. Past medical history is notable for moderate chronic obstructive pulmonary disease, and he was admitted for an exacerbation a year ago. Blood pressure is 145/90 mmHg and pulse is 93/min. Oxygen saturation by pulse oximetry is 98% on room air. Physical examination shows no heart murmurs, and lungs are clear to auscultation. ECG shows sinus rhythm with 2-mm ST elevation in leads II, III, and aVF. Cardiac troponin I levels are elevated. Which of the following is the most appropriate treatment for this patient?
(Ibutilide, Metoprolol, nadolol, propranolol, sotalol)
> Contraindications to beta blockers include bradycardia or heart block, hypotension, and overt heart failure (eg, pulmonary edema(.
> In addition, non-cardioselective beta blockers (eg, propranolol, nadolol) can trigger bronchospasm in patients with underlying
obstructive lung disease
Cardioselective beta blockers
with predominant action on beta 1 receptors (eg. metoprolol, atenolol, bisoprolol, nebivolol) are safe in patients with stable obstructive lung disease and are the drug of choice in these patients.
> Combined beta and alpha receptor blockers (eg. cardvedilol, labetalol) are also well tolerated and have been safely in patients with COPD.
uWORLD: A 34 yo woman is being evaluated for fatigue and progressive exertion dyspnea. She goes mountain biking with friends a few times a month and recently noticed that she has to stop and rest more frequently when traveling uphill. The patient has no significant medical history and takes no medications. She occasionally drinks alcohol but does not use tobacco or illicit drugs. her father died of a myocardial infarction at age 72. Lung auscultation is normal. An echocardiogram shows an enlarged coronary sinus. Which of the following is the most likely cause of the observed finding in this patient?
> Most of the venous drainage from the myocardium traverses the
, which delivers deoxygenated blood to the right atrium.
> The most common cause of
coronary sinus dilation
evident on echocardiography is
elevated right-sided heart pressure
uWORLD: A 64 yo man with a long-standing history of HTN is brought to the ED with a dry cough and SOB. The patient has bene unable to sleep in the flat position for the past 2 days. blood pressure is 192/102 mmHg and pulse is 92/min and regular. Physical examination reveals an S4 and bibasilar crackles. He is started on intravenous nitroglycerin infusion and soon after reports significant symptomatic relief. Which of the following physiologic changes are most likely to occur following administration of this medication?
(Left ventricular end-diastolic pressure; peripheral venous capacitance; peripheral venous capacitance; systemic vascular resistance)
> Decrease Left ventricular end-diastolic pressure
> Increase Peripheral venous capacitance
> Decrease systemic vascular resistance
> Nitrates are primarily ventilators and increase peripheral venous capacitance, thereby reducing cardiac preload and left ventricular end-diastolic volume and pressure. Nitrates also have a modest effect on arteriolar dilation and cause a decrease in systemic vascular resistance and cardiac after load.
uWORLD: A 48 yo man comes to the office for a follow-up visit. He was diagnosed with hypercholesterolemia 6 months ago and has been strictly following dietary and lifestyle modifications as advised. The patient has no the medical problems. He does not use tobacco, alcohol, or illicit drugs. His father has diabetes mellitus and coronary artery disease. The patient's blood pressure is 126/70 mmHg and BMI is 33.1. Physical examination is normal. Laboratory studies show a current LDL level of 190 mg/dL. Which of the following should be obtained before starting statin therapy in the patient?
Liver transaminase levels
> Common side effects of HMG-CoA reductase inhibitors (statins) include muscle and liver toxicity. Hepatic transaminases should be checked prior to imitating therapy and repeated if symptoms of hepatic injury occur.
> Statins have no significant renal side effects.
uWORLD: A 6 yo is evaluated in the office for difficulty hearing. The patient has no ear pain, discharge, or upper respiratory symptoms. Initial testing suggests that he has bilateral sensorineural hearing loss. He has no motor deficits or cerebellar signs. his paternal uncle died suddenly at age 12. Examinations of the ears, nose and throat is normal. ECG shows normal sinus that with a prolonged QT interval. Echocardiogram shows normal left and right ventricular function with no significant valvular disease. A genetic defect affecting which of the following is most likely present in this patient?
> Jervell and Lange-Nielson syndrome is an autosomal recessive disorder characterized by profound bilateral sensorineural hearing loss and congenital long QT syndrome, which predisposes to ventricular arrhythmias and sudden cardiac death. This condition occurs secondary to mutations in genes that encode voltage-gated potassium channels.
uWORLD: A 66 yo man comes to the ED due to several episodes of lightheadedness and a recent fall. The symptoms are especially pronounced in the morning when he gets up from bed. The patient takes medications for hypertension, stable angina pectoris, gout, and benign prostate hyperplasia. He also has osteoarthritis of the right knee and takes occasional NSAIDs. His blood pressure is 120/80 mmHg and pulse is 70/min in the supine position, and 90/60 mmHg and 87/min on standing, respectively. Cardiopulmonary examination is normal. Blockade of which of the following receptors is most likely contributing to this patient's current condition?
> Orthostatic hypertension is a frequent cause of lightheadedness and syncope and is defined as a decrease in systolic (>20 mmHg) or diastolic (>10 mmHg) blood pressure on standing from the supine position. Medications (alpha1-adrenergic antagonists, diuretics), volume depletion, and autonomic dysfunction are common causes of orthostatic hypotension
> alpha-1 agonist (Midodrine, Phenylephrine)
> alpha-1 antagonist (Doxazosin, Terazosin)
> alpha 2 agonist (Clonidine)
> beta agonist (isoproterenol)
> Beta 1 antagonist (metoprolol, atenolol)
uWORLD: A 10 yo boy is brought to the physican by his parents due to restlessness and involuntary jerking. He takes no medications and his vaccinations are up-to-date. His parents do not recall any recent injuries or illnesses other than a score throat 3 months ago. On examination, the patient has rapid, irregular jerking movements involving his face, arms, and legs. This patient is at greatest risk for developing which of the following conditions?
(Deforming polyarthritis, early dementia, parkinson disease, renal failure, valvular heart disease)
Valvular heart disease
> Sydenham chorea presents with involuntary, rapid, irregular jerking moments involving the face, arms, and legs. It course months after group A streptococcal infection and is one of the major clinical manifestations of acute rheumatic fever. Patients with this condition carry a high risk of chronic valvular disease.
All diuretics expect for the ___________________ class
causes potassium loss
. They do this by increasing the volume delivered to the collecting duct, where aldosterone then attempts to reclaim the additional volume at the expense of potassium.
> Potassium-sparing diuretics act on the late distal tubule and cortical collecting duct to antagonize the effects of aldosterone.
uWORLD: A 56 yo man omes to the ED due to progressively worsening dyspnea. He can walk only a few blocks before becoming SOB. He also finds it difficult to sleep lying flat and requires three pillows to prop himself upright when sleeping. The patient does not use tobacco, alcohol, or illicit drugs. His other medical problems include chronic hypertension, but he takes medication only when experiencing headaches. Blood pressure is 170/100 mmHg and pulse is 80/min. Physical examination shows bilateral basilar lung crackles, JVD, and bilateral lower extremity edema. A chest x-ray rivals cardiomegaly and hilar prominence. An ECG shows left ventricular hypertrophy. An echocardiogram shows pulmonary arterial hypertension. Which of the following is the most likely underlying mechanism for this patient's pulmonary hypertension?
Vasoconstriction due to pulmonary venous congestion
> Left-sided heart disease can cause pulmonary hypertension by increasing pulmonary venous pressure and congestion. This leads to a passive increase in pulmonary artery pressure, which is made worse by reactive vasoconstriction and structural remodeling of the pulmonary vasculature secondary to impaired nitric oxide availability and increased endothelia expression.
uWOLRD: A 68 yo man comes to the ED due to lightheadedness, generalized weakness, and palpitations. The patient has a prolonged hoister of HTN and take amlodipine. He does not use tobacco or alcohol. His blood pressure is 110/60 mmHg and pulse is 144/min and irregular. EG shows an irregularly irregular rhythm and absent P waves. The patient is started on beta blocker therapy for rate control, with improvement in his heart rate. Long-term anticoagulation is initiated to prevent atrial thrombus formation, and he is eventually discharged home on warfarin. Which of the following is the best test to monitor the anticoagulation effect of warfarin in this patient?
> Warfarin is an oral anticoagulant that inhibits the carboxylation of Vitamin K-dependent coagulation factors II, VII, IX, and X. It is used in atrial fibrillation, deep venous thrombosis, and pulmonary thromboembolism. Prothrombin time (PT)/Internatiaonl Normalized Ratio (INR) should be monitored regularly during treatment with warfarin. Activated partial thromboplastin time (aPTT) is used for monitoring unfractionated heparin.
uWORLD: A 66 yo Caucasian male presents to your office with a several month history of straining during urination, hesitancy and intermittent urinary flow. Upon reviewing his medical record, you also note that his blood pressure was high (160-170/95-100 mmHg) during his last several check-ups. He is not taking any medications. Which of the following drugs would address both of this patient's current problems?
(Doxazosin, metoprolol, ramipril, HCTZ, eplerenone, amlodipine)
> Alpha1-blockers such as Doxazosin, Prazosin, and Terazosin are useful for the treatment of both benign prostatic hyperplasia and hypertension
> They act by blocking alpha-1 adrenergic receptors leading to a relaxation of smooth muscle in arterial and venous walls leading to a decrease in peripheral vascular resistance.
> Patients with coronary artery disease and heart failure along with hypertension will benefit from cardioselective beta-blockers.
> Hydrochlorothiazide is presently the first-line medication for the treatment of essential hypertension in the general population.
uWORLD: A 12 yo girl is brought to e physican by her parents, who are concerned about her loss of interest in playing sports at school. During a recent competition, she walked off the field in the middle of the game, complaining about the pain in her legs. The patient has no other medical conditions and take no medications. Her vaccination schedule is up-to-date. Physical examination shows pustule vessels within the intercostal spaces and diminished femoral pulses relative to brachial pulses. This patient's symptoms are most likely associated with which of the following conditions?
________________ (genetic disorder) is associated with
coarctation of the aorta
in up to 10% of cases. Aortic coarctation is a child/young adult presents with lower-extremity claudication (eg. pain and cramping with exercise), blood pressure discrepancy between the upper and lower extremities, and delayed or diminished femoral pulses.
uWORLD: A 14 yo girl is brought tot he office for a routine physical examination. The patient will be starting her freshman year of high school soon. She plays the clarinet in the school band but does not play any sports. The patient says that she is not sexually active and does not use tobacco, alcohol, or illicit drugs. Height is at the 5th percentile, and weight is at the 25th percentile. Her temperature is 36.7 (98 F), blood pressure is 120/80, pulse is 88/min, and respirations are 16/min. Physical examination shows a short and tick neck, broad chest, and shortened fourth metacarpals. A murmur is heard on cardiac auscultation. Which is most likely seen in echocardiogram?
Bicuspid aortic valve
> Turner syndrome is associated with congenital anomalies of the aorta, and the most common defect is a bicuspid aortic valve. A nonstenotic bicuspid aortic valve can manifest as an early systolic, high-frequency click over the right second interspace. Bicuspid aortic valves are at risk for stenosis, insufficiency, and infection
Complete atrioventricular canal, ASD, VSD are the most common cardiac anomalies in _______________. Fixed splitting of the second heart sound is characteristically heard with an ASD, whereas VSDs produce a holoystolic mummer at the left lower sternal border.
uWORLD: A 1-day-old infant in the newborn nursery is found to have a harsh, holosystolic mummer on physical examination. The neonate was born at 39 weeks gestation to a 36-yo woman who opted to defer prenatal screening. Review of medical records show no family history of genetic or chromosomal disorders. The infant's vital signs are appropriate for his age. The rest of the physical examination shows a flat facial profile, protruding tongue, and small ears. Which of the following most likely occurred prior to conception?
> Down syndrome is most commonly caused by maternal meiotic nondisjunction, a process by which the fetus receives 3 full copies of chromosome 21. Dimorphic features (eg. flat facial profile, protruding tongue, small ears, up slanting palpebral fissures) and cardiac defects (eg. endocardial cushion defects) are characteristic.
Chromosomal deletions are associated with ______________, ________________, _________________
> Cri-du chat syndrome (5p deletion)
> DiGeorge syndrome (22q11 micro deletion),
> Prader-Willi syndrome (15q deletion).
Deletions are NOT associated with increased maternal age.
uWORLD: A 56 yo man comes to the office to discuss elevated blood pressure. He has had several measurements in the hypertensive range on a home blood pressure cuff. The patient feels well and has no significant past medical history. His father had a stroke at age 60. The patient's blood pressure is 152/95 mmHg and pulse is 75/min and regular.
At a subsequent visit, blood pressure is 162/92 mmHg, and the patient is started on low-dose chlothalidone monotherapy. The serum level of which of the following is most likely to increaein response to this treatment?
> Thiazide diuretics raise serum calcium, uric acid, glucose, cholesterol, and triglyceride levels. They lower serum sodium, potassium, and magnesium levels.
inhibit Na+/Cl- co-transporters
in the distal convoluted tubule, thereby decreasing reabsorption of Na+ and Cl-.
uWORLD: 1 34 yo previously healthy man comes to the ED due to a 3 hour history of chest pain, diaphoresis, and dyspnea. He does not smoke, exercises regularly, and eats a balanced diet. His father died at age 56 from a MI. his blood pressure is 110/70 and pulse is 110/min and regular. Physical examination is unremarkable. ECG shows ST elevation in the anterolateral leads. Coronary angiogram reveals proximal left anterior descending artery stenosis and thrombosis, which is treated with angioplasty and stent placement.
Lab shows elevated homocysteine plasma.
Further testing reveals a homozygous mutation in the methylene tetrahydrofolate reductase gene that leads to decreased enzymatic activity. Due to this defect,
> Elevated levels of plasma homocysteine are an independent risk factor for thrombotic events. Homocysteine can be metabolized to methionine via remethylation or to cystathionine via transsulfuration.
> Hyperhomocysteinemia is most commonly due to genetic mutations in critical enzymes or deficiencies of vitamin B12, vitamin B6, and folate
uWORLD: A 78 yo man comes to the office due to a one-month history of progressive dyspnea, generalized weakness, fatigue, and palpitations. He also reports tingling and numbness in both lower limbs. His daughter, who is visiting from another state, adds that since his wife's death a year ago, the patient has not been taking care of himself. BP is 105/50 and pulse is 104. Cardiovascular examination shows a displaced apical impulse at the sixth intercostal space, a third heart sound, and high-volume, collapsing carotid pulses. Bilateral basal crackles, 2+ bilateral pedal edema, and mild hepatomegaly are also present. Neurologic examination shows decreased light touch and vibration sense in the feet, with decreased knee and ankle reflexes bilaterally. Laboratory evaluation shows normal blood counts. Deficiency of which of the following nutrients is most likely responsible for this patient's symptoms?
(Ascorbic acid, cobalamin, niacin, pyridoxine, retinol, riboflavin, thiamine)
> Thiamine defiance causes beriberi and Wernicke-Korsakoff syndrome. Dry beriberi is characterized by symmetrical peripheral neuropathy; wet beriberi includes the addition of high-output congestive heart failure.
uWORLD: A 64 yo man with stable angina is being treated with atenolol and aspirin. He reports that over the last week, his symptoms have been worsening. His physician decides to add a new medication to his regimen. Several days later, he presents to the ED complaining of severe dizziness. On physical examination, his blood pressure is 100/70 and his heart rate is 38 bpm. Which of the following medications was most likely administered.
(Nifedipine, captopril, verapamil, isosorbide denigrate, prazosin)
> Combined use of non-dihydropyridine calcium channel blockers (eg. verapamil, dilitizem) and beta-adrenergic blockers (eg. atenolol) can have additive negative chronotropic effects yielding severe bradycardia and hypertension)
uWORLD: A 12 yo Caucasian male is found to have a wide, fixed splitting of the second heart sound (S2) on routine physical examination. He denies any symptoms. If present, the congenital heart disease in this patient may require surgical repair to prevent irreversible changes in the:
> Wide, fixed splitting of the second heart sound is characteristic auscultatory finding in patients with ASD.
> A hemodynamically significant ASD can produce chronic pulmonary hypertension as a result of left-to-right intracardiac shunting.
> Eisenmenger syndrome is the last-onset reversal of left-to-right shunt due to pulmonary vascular sclerosis resulting from chronic pulmonary hypertension.
> Pulmonary hypertension produced by an ASD could result in right ventricular hypertrophy and right atrial enlargement. However, these changes are not necessarily irreversible. If the pulmonary hypertension is corrected, the right heart can revert to more normal morphology
uWORLD: A 50 yo Caucasian female with a history of breast cancer treated by radical mastectomy and radiation several years ago, now resents with persistent right arm swelling. This patient is at increased risk of developing?
> Persistent lymphedema (with chronic dilatation of lymphatic channels) predisposes to the development of lymphangiosarcoma, a rare malignant neoplasm of the endothelial lining of lymphatic channels. This cancer may arise approximately 10 years after radical mastectomy with axillary lymph node dissection for breast cancer.
uWORLD: A 57 yo man is seen in the office after an episode of acute pancreatitis. Hospital evaluation found no evidence of gallstones. The patient does not consume alcohol, but he does have a history of severe hypertriglyceridemia. He was treated with a vibrate medication in the past but could not tolerate it due to liver toxicity. He has no history of diabetes mellitus or phyertension. On examination, the patient has no abdominal tenderness. Laboratory studies show normal hepatic and pancreatic enzyme levels, but the patient again has a severely elevated triglyceride level. The physician prescribes the appropriate medications and explains that the patient is likely to experience skin flushing and warmth after taking the pills. Which of the following is the primary agent medicating these side effect?S
> Niacin is used in the treatment of hyperlipemia. It increases HDL levels and decreases LDL levels and triglycerides. Niacin causes cutaneous flushing, which is mediated by prostaglandins and can be diminished by pretreatment with aspirin.
___________________ is a potential side effect of selective serotonin reuptake inhibitors. It is characterized by abnormal mental status, autonomic hyperactivity, and muscular rigidity with hyperreflexia.
uWORLD: A 67 yo male present to your office with a history of progressive dyspnea. He cannot tolerate moderate exertion and sleeps in a half-sitting position due to orthopena. he has also noted some swelling of his ankles. He does not smoke or consume alcohol. His past medical history is significant for hypercholesterolemia and recurrent chest pain. Which of the following do you expect to be increased in this patient?
> Decreased cardiac output triggers a number of compensatory mechanisms. Renin-angiotensin-aldstoerone activation and increased sympathetic output raise arterial resistance (after load) and exacerbate heart failure by making it more difficult for the failing heart to pump blood to the tissues.
uWORLD: A 5 week old boy is being evaluated for a week-long history of rapid breathing and tiring with feeds. The infant was born at home after an uneventful pregnancy. The mother declined all prenatal testing and ultrasound evaluations. His temperature is 98 F, blood pressure is 76/38 mmHg, pulse is 124/min, and respirations are 66/min. The patent's cardiovascular examination is notable for a hyper dynamic precordium, a mid-diastolic rumble at the left sternal border, and a 3/6 holosyotlic murmur in the apex that radiates to the left axilla. An echocardiogram shows defects in the lower part of the intertribal septum and the interventiuclar septum. This patient's condition is most likely associated with which genetic conditions?
> A complete atrioventricular (AV) canal defect is comprised of an ASD, VSD, and a common AV valve. It is the most common congenital cardiac anomaly associated with Down syndrome.
uWORLD: A 12 day old boy in the neonatal intensive car unit has feeding intolerance that worsened over the past 2 days. The infant was born 27 weeks gestation, but was only intubated for 2 days. The infant's birth weight was 1150 g. His temperature is 37 (98.6 F), blood pressure is 41/12 and pulse is 182/min. Physical examination shows a well-appearing, vigorous infant. A continuous murmur with systolic accentuation is heard best at the left heart border. Peripheral pulses are normal. Abdominal examination is unremarkable. A blood culture is sterile. Production of which of the following is causing this infants condition?
> Patent ductus arteriosus is common in preterm infants and presents with a continuous murmur, widened pulse pressures, and signs of cardiovascular strain. Indomethacin or ibuprofen therapy can inhibit prostaglandin E2 synthesis and accelerate closure.
uWOLRD: A 16 yo boy suddenly collapses while jogging and dies despite resuscitation efforts. He has no history of medical problems; however, his family history is significant for an uncle who died suddenly at age 20. Autospy reveals significant left ventricular hypertrophy predominately affecting the inter ventricular septum. There are no valvular abnormalities. Assuming the boy died of an inherited condition, which of the following proteins was most likely affected by the relevant mutation?
beta-myosin heavy chain
uWORLD; A 65 yo Caucasian male admitted following an acute ST-segment elevation MI experiences chest pain on day four of his hospitalization. He describes the pain as sharp in quality, and adds that it increases with coughing and swallowing and radiates to his neck. The blood pressure is 130/80, pulse is 90 ppm, temp is 101 F and respirations are 20 per min. Which is the most likely cause of the patient's chest pain?
pericardial inflammation overlying the necrotic segment of myocardium
> In constrast to angina, the chest pain of pericarditis is
sharp and pleuritic
, and may be exacerbated by swallowing or relived by leaning forward. Early-onset pericarditis develops in about 10-20% of patients between days 2 and 4 following a transmural MI. It represents an inflammatory reaction to cardiac muscle necrosis and occurs in the adjacent visceral and parietal pericardium. Late-onset post-myocardial infarction (MI) pericarditis (Dresseler's syndrome) begins one week to a few months following the MI, and affects less than 4% of cases. Dresser's syndrome is though to be an autoimmune polyserositis.
> Dressler's syndrome is thought to be an autoimmune polyserositis provoked by antigens exposed or created by infarction of the cardiac muscle. Thus, the pericardium is usually diffusely inflamed. Dressler's syndrome generally responds to aspirin, NSAIDS, and/or glucocorticoids.
uWORLD: A 76 yo woman is brought to the ED by her son due to lethargy and confusion over the past 2 day.s. The patient has persistent atrial fibrillation and congestive heart failure and is on multiple medications. Recently, she has had nausea and decreased appetite. Today, she had 3 episodes of vomiting. The patient also reports vision difficulties. Temperature is 98 F and blood pressure is 133/80.
Labs show elevated potassium levels.
ECG shows junctional escape rhythm at a rate of 48/min with occasional ventricular premature beats. Increased blood level of which of the following medications is most likely responsible for symptoms?
(Amidarone, aspirin, digoxin, dilitlizem, furosemide, metoprolol, spironolactone, valsartan)
> Digoxin toxicity typically presents with cardiac arrhythmias and nonspecific gastrointestinal (nausea, vomitting), neurological (confusion, weakness), and visual symptoms. Elevated potassium is another sign of digoxin toxicity and is caused by inhibitor of Na-K-ATPase pumps.
> Color vision alterations is a neurologic side effect of digoxin.
Mutations in the _______________ gene are responsible for hereditary form of cardiac amyloidosis. Amyloid deposition in the myocardium results in infiltrative cardiomyopathy, which typically presents in adults with progressive dyspnea, peripheral edema, and ascites.
Mutations in the ____________ gene are responsible for X-linked familial dilated cardiomyopathy. These mutations are also found in the common skeletal myopathies (
Becker muscular dystrophy
), which are both associated with cardiac involvement
uWORLD: A 55 yo man comes to the ED with recurrent episodes of retrosternal chest pain.. The episodes occur during a during physical activity usually when he climbs stairs or walks uphill. The patient has no known medical problems and does not use tobacco, alcohol, or illicit drugs. he is given a sublingual tablet and reports repaid relief of the pain. The drug most likely improve the patient's symptoms by causing which of the following hemodynamic changes?
Decrease in left ventricular end-diastolic vol
> Sublingual nitroglycerin is used for rapid symptoms relief in patients with stable angina. The primary anti-ischemic effect of nitrates is mediated by ventilation with a decrease in left ventricular end-diastolic volume and wall stress, resulting in decreased myocardial oxygen demand and relief of angina symptoms.
> Nitrates dilate the large epicardial arteries more than the smaller resistance vessels (eg. arterioles). Furthermore, coronary arterioles in an area of flow-limited stenosis are typically dilated maximally to maintain resting blood flow, listing the ability of nitrates to significantly increase blood flow in stenotic coronary arteries.
uWORLD: a 54 yo man comes to the office for evaluation of HTN. he was diagnosed with HTN 2 years ago but has had inconsistent follow-up and has not seen a physician in the las 6 months. The patient is not currently taking any medications but feels well and has good exercise tolerance. He has a family history of HTN and ischemic stroke. His BMI is 26 kg/m. Physical examination is unremarkable. Serum creatinine level is normal. The patient is started on valsartan and HCTZ, and the following values were measured at baseline (before starting treatment) and after 3 weeks of therapy.
Baseline 165/95 BP
After 3 weeks: 162/96 BP
Renin: 2.5 before and after 3 weeks.
>Plasma renin activity (PRA) is a measure of the amount of angiotensin I generate per unit of time.
> Because this patient's Plasma renin activity (PRA) did not increase after being prescribed valsartan and HCTZ, this suggests likely medication noncompliance.
uWORLD: A 23 yo Caucasian male who notes recurrent severe nosebleeds is found to have pink spider-like lesions on his oral and nasal mucousa, face, and arms. The patient most likely suffers from:
Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) is an autosomal dominant condition marked by the presence of telangiectasis in the skin as well as the mucous membranes of the lips, oronasopharynx, respiratory tract, gastrointestinal tract, and urinary that. Rupture of these telangiectasias may cause epistaxis, GI bleeding or hematuria.
__________________ is an inherited peripheral nervous system tumor syndrome. Patients develop neurofibromas, optic nerve gliomas, Lisch nodules (pigmented nodules of the iris), and cafe au last spots (hyper pigmented cutaneous macules)
Von Recklinghausen's disease / Neurofibromatosis type 1 (NF1)
___________________________ is an autosomal dominant nervous system tumor syndrome, in which patients commonly develop bilateral cranial nerve VIII schwannomas and multiple meningiomas.
Neurofibromatosis type 2
uWORLD: A 68 yo Caucasian male presents to your office complaining of fatigue and difficulty carrying out his normal daily activities. He has a history of HTN, type 2 diabetes mellitus, and osteoarthritis. He has smoked one pack of cigarettes per day for the past 40 years. Which of the following would most likely indicate left-sided heart failure in this patient?
Supine dyspnea that is relieved by sitting up
> Orthopnea is a quite specific sign of left-sided heart failure. Bilateral lower extremity edema and congestive hepatomegaly are more specific for right-sided heart failure. Left-sided heart failure may also produce a productive cough and exceptional wheezing or chest tightness, but these are nonspecific signs seen in a variety of disorders.
uWORLD: A 67 yo man admitted for right lower lobe pneumonia subsequently develops hypotension and lactic acidosis. He is started on a norepinephrine intravenous drip. A few ours later, the antecubital vein being used for the infusion blanches and the tissues surrounding the IV site become cold, hard, and pale. Local infection of the affected tissues with which of the following agents is most likley to be of greatest benefit:
> Blanching of a vein into which norepinephrine (NE) is being infused together with induration and pallor of the tissues surrounding the IV sites are signs of NE extravasation and resulting vasoconstriction. Tissue necrosis is best prevented by local injection of an alpha1 blocking drug, such as phentolamine.
uWORLD: A 63 yo Caucasian male presents to the ED with severe dyspnea, orthopnea and fatigue. He suffered a MI six months ago, and has not been compliant with his medications since that time. On exam, his blood pressure is 170/100 mmHg and his heart rate is 100 beats per minute. Auscultation reveals crackles at the lung bases, an S3 gallop, and a II/VI holosystolic mummer over the apex. After initial treatment with diuretics and vasodilators the patient's condition improves significantly. The next morning, there are no appreciable gallops or murmurs on cardiac exam. The murmur heard at the time of presentation is most likely explained by:
Functional mitral regurgitation
> Acute hemodynamic changes can produce functional heart murmurs, in the absence of any fixed valve lesion. Dilatation of the left ventricle in responses to increased preload can result in functional mitral regurgitation, which can be eliminated by preload reduction and reduced by after load reduction.
Chordae tendineae rupture producing severe mitral regurgitation (MR) is complication of _____________________, and less frequently of connective tissue diseases or acute myocardial infarction. When papillary muscle or chore rupture occurs in association with myocardial infarction, it is usually an early complication of the MI (i.e occurring within 10 days).
uWORLD: A 36 yo woman is brought to the ED with sudden-onset right side weakness and speech difficulty. During the last 3 weeks, the patent has experienced progressive fatigue, malaise, and low-grade fevers. Despite the symptoms, she did not seek medical attention and did not take any medications. She had a dental extraction 5 weeks ago, which was uncomplicated. The patient has never previously been significantly ill or hospitalized. She worked as a receptionist at a legal firm and has never raveled outside the United States. She does not use tobacco, alcohol, or illicit drugs. The patient is admitted to the hospital, but despite adequate resuscitative measures, she dies 2 hours later. Gross autospy shows large, friable irregular masses attached to the atrial surface of a valve. Which of the following underlying conditions most likely predisposed this patient to her presenting disease?
Regurgitant mitral valve prolapse
> Mitral valve prolapse with regurgitation is the most common predisposing condition for native valve infective endocarditis (IE) in developed nations. Rheumatic heart disease remains a frequent cause of IE in developing nations.
> The patient had
subacute infective endocarditis (IE)
complicated by an
. The large, friable irregular masses seen on autospy are most likely vegetations and are the most probable source of the embolus that lodged in the one of the patient's intracranial arteries (presenting symptoms indicate the left middle cerebral artery)
uWORLD: A 47 yo man comes to the office for follow-up of his elevated blood pressure. The patient's medical history is significant for stable angina pectoris, for which he takes sublingual nitroglycerin as needed. He has no orthopnea, paroxysmal nocturnal dyspnea, or lower extremity swelling. His blood pressure is 154/107 mmHg and pulse is 86/min. Physical examination shows no abnormalities. The patient is started on a low dose of atenolol. Which of the following cellular changes will most likely occur as a direct effect of this medication?
(Cardiomyoctye [cAMP], juxtaglomerular cell [cAMP], Vascular smooth muscle [cAMP])
Cardiomyocyte [cAMP] - decrease
Juxtaglomerular cell [cAMP] - decrease
Vascular smooth muscle [cAMP] - No significant change
> B1 adrenergic receptors are found in cardiac tissue and on renal juxtaglomerular cells, but not in vascular smooth muscle. Selective blockade of the beta-1 receptor (eg. with atenolol) leads to decreased cAMP levels in cardiac and renal tissue without significantly affecting cAMP levels in vascular smooth muscle.
uWORLD: A group of forensic pathologists are analyzing tissue samples of adolescents age 13-18 to study the aging process. Autospy of a 14-year-old boy who died in a motor vehicle accident shows several minimally raised yellow spots on the inner surface of the abdominal aorta. The rest of the cardiovascular findings during the autospy are unremarkable. He had no known medical problems. There was no family history of cardiovascular disease or sudden cardiac death. Which of the following is most likely to be the predominant cell type in these lesions on light microscopy?
> Fatty streaks are the earliest lesions of atherosclerosis and can be seen as early as the second decade of life. They appear as a collection of lipid-laden macrophages (foam cells) in the intimal that can eventually progress to atherosclerotic plaques.
uWORLD: A 34 yo man is brought to the ED with severe headache and blurry vision. His symptoms began suddenly after having lunch at a new Italian deli in his neighborhood. The patient says he "ate a sandwich with lots of fancy meats and cheeses" and drank an iced tea. His past medical history is significant for severe, atypical depression. He has no known medication or food allergies. His blood pressure is 210/130 and heart rate is 100/min. On physical examination, he appears tremulous and diaphoretic. The medication used to treat this patient's depression most likely affects which of the following steps of monoamine neurotransmission?
> This patient is experiencing a
(severe hypertension, headache, blurry vision) and has signs of excessive sympathetic activity (tachycardia, diaphoresis, tremors), most likely as a result of ingesting
(eg. aged cheeses, cured meats, draft beer).
> Monoamine oxidase (MAO) is a mitochondrial enzyme that degrades excess monoamine neurotransmitters in presynaptic nerve terminals and detoxifies dietary tyramine in the gastrointestinal tract. Tyramine hypertensive crisis can occur in patients taking MAO inhibitors following the consumption of foods containing high amounts of tyramine (eg. aged cheeses, cured meats, draft beers).
uWORLD: A 45 yo man who was recently started on medication for paroxysmal atrial fibrillation undergoes stress ECG testing. The patient exercises on a treadmill for 9 minutes and reaches 98% of age-predicted maximal heart rate without chest pain or ST-segment changes. His pre-testing resting QRS complex duration is 95 msec (normal) and corrected QT interval duration is normal. ECG finding recorded at his maximally achieved heart rate shows a QRS complex duration that increased and QT interval duration that decreased. Based on the patient's test results, which of the following medications is most likely being used to treat his atrial fibrillation?
(Atenolol, digoxin, dofetilide, flecainide, verapamil)
> Class 1C antiarrhythmics such as flecainide are potent sodium channel blockers that have increased effect at faster heart rates (used-depdencne). This makes them more effective at treating tahyarrhythmias, but can also cause prolonged QRS duration (a pro arrhythmic effect) at higher heart rates
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